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_APPLICATION FOR SANITATION PERMIT Permit No. (Complete in Duplicate) f a ,SY Date Issued . ______ k0A�plicati�n is hereby made to the San Joaquin Local Heal h District for a pe mit to c nstruct and install the work herein described. lication is made m com liance with-County Or m meNo:, 9.Ts app r JOB ADDRESS AN lCATI N•-� _____ _ _____________ ---- -------------------•------------------------------------------------------------------- Owner's Name. -------------- I -------------------------------- IPhone I ------ ------ -�--- E Address . -------_-----------• --------------------•----------•--------------------- i Contractor's Name.__ .....-- � ---- ---------------- ---- -- -=- --------• ------ ----------- Phone---------------------------------- Instaliation will serve: Residence Apartment House ❑ Commercial ❑- Trail* Cour��❑r Motpl ❑ them ❑ //ilk' t D �-V b-I Number of living units: __.�___ Number of b�drooms �-- Number o �aths __(-____ Lot size - --------------------------- Water -------- ------------ --Water Supply: Public system ❑ Commu�Rty s stem ❑ Private Dep*Cto Water Tale __..-'_ ft. Character of soil to a depth of 3 feet:I ' 'a7�0 GraevfI ❑ Sandy Loam ' Clay Loam Q Clay ❑ Adobe Hardpan ❑ Yes No ew Construction: Yes ;No ❑ Previous Application Made ❑ ��.. TYPE OF INSTALLATION AND SPECIFICATIO S: Na septic tank or cesspool permitted if ublicsewer i available within 200 feet.} Septic/ank: Distance from nearest well--- ,------Dist nqe frnoorr foun ion- ateri I /� - No. of com artments--- Siz ,--'- . ----- Liquid dap s Capacity =d Dispos Field: Distance froom nearest welL0__.-__Distance from found io ____ ir Distance to nearest lot line- --- ----------- Number of lines_______.__ Z!_____._ _Length of each line-U10 Width of trench__--_-_-___ '7� g �t j ---------- Type of filter materi ,_:Depth of filter material--------j. ____-__.Total length-----------LZ-0_________________ Seepage Pit: Distance to nearest well-___________________}Distance frorrifoundation--------------------Distance to nearest lot line----------------- ❑ Number of pits----------------------Lining material---------------------- Size: Diameter-- ---------------------Depth--------------------------------- Cesspool: Distance from nearest well-_- -_-________Distance from foundation___________________Lining material--------____--._____.______.__.__.___. ❑ Size: Qiameter---------------- ---:. Depth----_-------------------------- _ LiquiddiCapacitY--------------------_ gals.:.... } . _______________________Distance from nearest building Priv '� ""r Distance from inearest'well-----' g Y� ❑ Distance to,nearest lot line-- ------------------------------------------------------------------------------------------ ----------------------------------------- Remoling nd/or repairin de be) _ __.___.__ �L{ --------------------------------------------------•-----------•-----------------------•------------------------------------------------------ ia ---er --•------------------------------------•------------------------------------ ---------------------------------------- i I hereby certifyjhat I,have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State laws, a.nd r les and'regulations of he San Joaquin Local Health District. (� ----------------------------- ------------------(Owner and/or Contractor) sY*-- --------_-- ------==-------• ;; ----------------------------------------------(Title)------------------ -I--------------------- - ------------- (Plot plan, showing sizelof lot, location of system in relation to wells, buildings, etc., can be placed on reverse side}. + FOR DEPARTMENT USE ONLY APPLICATION\ACCEPTED BY. ---------------------- ------------=----------------------------------------------------- DATE---�----------------------------------------------------- REVIEWEQ BY = ------------------------------------------------------ DATE_--1*1Z- PERMIT ISSUED------------ ....... = DATE Alterations and/or r commendationst____________________________._--__._. ----------------------------- -------- Alterations = '�.-` . --_ f �. I 11 i ------------------- ------------------------------------------------- -----------------_------ _______________ __________..__- -.___. FINAL INSPECTION BY:. Date-- `------, F SAN JOAQUIN LOCAL HEALTH DISTRICT I 130 South American Street 300 West Oak Street 132 Sycamore Street 814 North "C" Street Tracy, California 1 S#ock+on, California Lodi, California Manteca, California � 1 E5-9-2M 10-52 Revised W-2100