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i 7,7 e I \2 1 APPLICATION FOR SANITATION PERMIT Permit No. ` \� (Complete in Duplicate) Date Issued A_bL:7 .3 Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described. This application is made in compliance with County Ordinance No. I..1. JOB ADDRESS AND OC TION..-- cG 1 ._..... err `��t_' Owner's Name--- -- rz .. Phone ------- ......... " Address _Z- ' :. = ------------------------------------------••--•----------------------------------------------------------------------- r Contractor's Name----------- = z Phone Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: Number of bedrooms-. Number of baths _/__- Lot size _ ____ f `-= ------------------___- Water. Supply: Public system ❑ Community system ❑ Private Depth to Water Tabls,-�__�ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe ' Hardpan ❑ Previous Application Made: Yes ❑ No, New Construction: Ye No ❑ `\ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Ta Distance from nearest well________________Distance from foundation....................Material --__..-_-__-_.-__.___---.--_---•.._--______-:--!�4 No. of compartments--------------------------Size-------------------------------Liquid depth--------------------------Capacity---------------------- Dispos�Fd: Distance from nearest well----------------Distance from foundation--------------------Distance to nearest lot line___•-__---_._-__. Number of lines-----------------------------------Length of each line------------------------------Width of trench_:__-_--__--__-___--__-________-__ Type of filter material----------------___------Depth of filter material-------------.---------Total length_.:_--_--_________-_______----_-----_-.-_-t" Seepa a Pit: Distance to nearest well_/f_____________Distance f m�f ndation__ ,C1._,_.....Distance to nearest lot line_-!_—___--__--- Number of pits.- .-li__._._-__-Lining material __ _._..Size: Diameter'_~_______Depth----ot$_v---------------- tw Cesspool: Distance from nearest well________________Distance from foundation_--_____-_____:__..Lining material-------------------------------------- vJ ❑ Size: Diameter---------------------------- ----Depth--------------------------------------------------Liquid Capacity----------------------------gals. Privy: Distance from e fr ----------------------------------- ❑ istance to nearest lot line--------- ------------------------------------------------------------- -----------------------------------------------------•---------------- Remodeling and/or repairing (describe):_---__ ._ I __.__--___........................................ ---•--••---------------------•---------•----------------------------------------•-----------------------------------------------•--------- -----------------------_---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- --------- --------------- •-----------...... -------------------------------------.......................--------------------------------------------•---•----------------------------------•----------------------------- I hereby certify that] have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State laws and rules #nd regulations of the San Joaquin Local Health District. (Signed)---------------- = -..... i• �.....'---------------------------------------------------------------- -(Owner an or Contractor) By:-------------------------- 4-_`-------------.__----------------------------------------------------------------(Title `x y' --------- (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be p ced on reverse sic FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY------------------- - ----- -- ---.................................................... DATE------//` �• =`��?, REVIEWED BY -_-- DATE------------------------------------------------------------ BUILDINGPERMIT ISSUED-------------------•-----------------------------------------•-----------------------------------•-- DATE------------------------------------------------------------- Alterations and/or recommendations------------ ---------------------------------------------------------------------------------------------------•--------------------------------------------- -•-----------------------------•-------------------------------------------•----------------•-•-------------•-----••-•------•---•---------...--•--------•--•••--••--•-•-----•-------------------•------•--•--------•---•-•---. ------------------------------------------------------•-----•---... ------------------------------------------------------------------------- ------------------------------------------------------------------------------ -----------------------------------------------------------------------------------------------------------------------------------------------------•------------------------------------------------------------- ------ ------------------------------------------------ -••------•- -------•--------- ----------------------------------------------------------- -------------------------------------------_---.---------------------•------- --------------------------------------------- FINAL INSPECTION BY---- -------- --" . Date 1 SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Street 814 North "C"Street Stockton, California Lodi, California Manteca, California Tracy, California 5-9-2M 10-52 Revised W-2100