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V APPLICATION FOR SANITATION PERMIT Permit No. f;.+ (Complete in Duplicate) Date Issued Applica+ion 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 Ord' e No. 54 . JOBADDRESS A D O TIO --- = A � = j --=----•------------------------- ------•----:-- ----------------- --------------- ---------------------- --- -- -- Owner's Name-------- --- Phone : .� .Address_'---- --- - ----------------------------- ---------- --•--------------------._...---------------------- ; Contractor's ame------------------------------- ---- = ------------------------ -------- ------------- --- - - e -- ------ - - - - - ----- )`,l Installation will serve: Residence ❑ partment House ❑ Commercial railer Court ❑ o e Other ❑ .,y - Number of living units:___ Number of bedrooms z�_ Number of baths zl-_ Lot size ____ ___"__ __ ____-_.._ Water Supply: Public,=system ❑ Community system ❑ Private Depth to Water Tablq'u_ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy LoamClay Loam ElClay ❑ Adobe El Hardpan [I Previous Application Made: Yes E] N< New Construction: Yes No ❑ F TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 fegqet� Septic ank: Distance from nearest welL��__.---Distance(from soundation__1_ _____(Material- ___11-W ______________ __________- /� IR No. of tom artments_._ _ Size__ / _ VX�__Liquid depth_, _ _.___.Capacity... p �----- ----- -- r� r� , i ----------- Disposal Field: Distance from nearest well_ / Distance from foundation../�----------Distance to nearest loI,tt liner_f__ Number of lines________ __ __________ _ _____Length of each line______ -----------Width of Type of filter material _ ___ ___ ____Depth of filter material-- length----------- ------ ______._ Seepage-'Pit: Distance to nearest well__--------------------Distance from foundation_:______.__.__:___-.Distance to nearest lot lin-e----------------- . # ❑ Number of pits------ i-------------Lining material-----------------------Size: Diameter------------------------Depth-----------------------------__- Cesspool: Distance from nearest well---------------Distance from foundation--------------------Lining material_____.-_-_____.________-___.____----- Size: Diameter--------------------------------------Depth--------------------------- -----------------------Liquid Capacity---------------------------.gals. Privy: Distance from nearest well------------------------'4________>_______________ istance from nearest buildin _ F� ❑ Distance to nearest lot line --------------------------------- ----------------- ---- ---------------- Remodeling and/ repairi (d ribe)________________ --------- r�-•--- ------ 4 -- - - - -• - --- -------- ----- --- ---- •---------.... - - -- ------------------•----------------------------------- -------------------------------------- - -r-- ----------------------- -------�----- g �t-rl = ¢ ............... --- - -----------`----------------------------------- --- .._..---------------•---------------------•-------------------------------•-------•--------------- ,! hereby certify that I have prepared fhis'applicatio th t the work will be done in accordance with San Joaquin Count ordinances, State law rules a d r ul io of the J On Local Health District. --------------------- wrier and/orContractor)(Signed) +-- ---- By:...... •---------------------- ! ------------------------------ --------------•----------------=-- - {Title) 1---------------------------- C (Plot plan, showing size of lot--- OC of system in relation to wells, buildings, etc., can be plat n re rse side). I. FOR DEPARTMENT USE ONLY N APPLICATION ACCEPTED BY_ _ DAT�L-------------------'-•------------------------------- REVIEWEDBY----------------------------- - ------------------------------------- --------------------------------------------- DATE e. BUILDINGPERMIT ISSUED------------------------------------------------------------------------------------------------------ DATE S ------------------------ Alterations and/or recommendations:--------- -----------•----------= ------•-------------- ----------------------------------------------------------------------------------------•-----------------------------•----------------•--••-------•-------------••-----------------------------•------ ------------------------- ---- ------ -------•- --------------------------------•-•---------------•----------- -------- ----------------------------------------------------------------- ------------------------------------------- FINAL .INSPECTION--BY:---- --------------------- Date..:------- = ----------------------•---- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 30D West Oak Street 132 Sycamore Street 914 North "C" Street I Stockton, California Lodi, California Manteca, California Tracy, California r ,rl, GC—o—lu P—".—a W_71no C