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APPLICATION FOR SANITATION PERMIT Permit No.3_, -.1�_______ (Complete in Duplicate) t 0 \ Date Issued .____/.._I-- Application is hereby made to the San Joaquin Local Health District for a permit to construct aZinslII the work herein described. This application is made in compliance with County Ordinance No. 5 9. JOB ADDRESS AND LO ATION___. �t�11_ !.CJi- - Owner's Name-------------- ----------------- ----- --•------- ---------- Phone ------ ------------------ Address------_-------------_ --- ------ ; = Contractor's Name............. ------ A--- ------ -- ----- --- ------------- f� �� Phone - ---�' Installation will serve: ResidenceApartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other Number of living units: j----- ber of bedrooms �?-_ Number of baths __/__ Lot size ____________-.- Water Supply: Public system Community system E] Private ❑ Depth to Water Table -------- ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ lay Loam ❑ Clay joAdober4olardpan Previous Application Made: Yes ❑ No lew Construction: Yes No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if��puubhc is available within 200 feet.) Septic Ta Distance from nearest well/Y!__ (d__tance from foundation_� ..._...__.Mater �_.. No. of com artments__ ___-Li uid de th.-.__ .' --__ Capacity----- ................ Disposal Fi Distance from nearest well-14_A "'Distance from foundatioV- 2 --_----Distance to nearest lot ine_,- ... []/ Number of lines____ Len th of each line___ ,j� ., g � Width of trench Type of filter material_X t_Depth of filter material___ ��:-__Total length_--.______ ................. Seepage Pit: Distance to nearest well__ ______________Distance from foundation.----_------------Distance to nearest lot line ❑ Number of pits_______________ Lining material_..--------------------Size: Diameter------------------------Depth ._.______ ____.--.___--_-___ Cesspool: Distance from nearest well-------------___Distance from foundation__ _______ ___-_.Lining material--._--___---___ ______-______-__.171 � Size: Diameter--------------------------------------Depth------_--_---------------------------------------Liquid Capacity- ---------------------_gals. Privy: Distance from nearest well________ _ ____________.---------------------Distance from nearest building------------------------------------------ F1 ___ _-_____-- _-.,---.__-_-___❑ Distance to nearest lot line-------- ------- _ ----- Remodeling and/or repairing (describ e): Z-VtZ �__ ---- ----------- ------- _ �_ -__ - „_ ! ..... -------------------•--------------------------------------------------------------------I-------'----•------•-•---------------•-------------------------------------------------------- - •-- --------- ----------------------------------------------- ------------------------------------------- -------------- ---•----------------------------------------- ----- ----------------------------- hereby certify that I have prepared this application and that the work will be done in accordance with Sen Joaquin County ordinances, State la s, and rules and re ulations of the San Joaquin Local HealyDistrict. (Signed)------------ - -`__-- -"-__--A., __ . ._ _ Owne �nd/or ntractor__-__ _ -_.___ ______________ __ __________ ( ) By:-----------— - ---------------------------------(Title)------ (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY_......___ --------------------------------------------------------------- DATE_ - REVIEWED BY-------------------------- -------- AV.,... DATE ��' T BUILDINGPERMIT ISSUED------_-----_------------ --------------------------------•--------------- --------- ----- DATE--------------------------------------- Alterations ---------------•--------- --- ----Alterations and/or recommendations ------------------ ---------- -•----------•------- ---•-- -----•-------------- ----•---------•----•---------- - FINAL INSPECTION BY:----------- � ------------------------------- Date---------� �- - --- . 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 ES-9-2M B-51 Revised W-2100