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d1�1„ry� APPLICATION FOR SANITATION PERMIT Permit No. .. �p .__ ( (Complete in Duplicate) Date issued _- Applicakion 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. 54 JOB ADDRESS AND LOCA N....- d - '---------- Owner's Name-------------------- -.--- -------- Phone- •-----• ------.---r.------------- .AddrAddress---------------------------- ess----------------------------- ------•----•---• ----------- •--------- --------------- -----••------------- ------ . Contractor's Name �7�f l d 4'l one_� � 4'��/ s- Installation will serve: Residence Apartment House ❑c� Commercial [-] Trailer Court [:] Motel ❑ Other t-- ❑ Number of living units: _ --- Number of bedrooms;?._ Number of bat s /_____ Lot size __- 4/ __ Water Supply: Public system ommunity system ❑ Private Depth to Water TableyQ_ ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam E] Clay Loam ❑ Clay Adobe❑ Hardpan E]Previous Application Made: Yes [I No New Construction: Yes (�/ o ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: t (No septic tank or cesspool permitted if public sewer is available within 240 feet.) Septic Tyn - Distance from nearest well__________ ______Distance from foundation____________ ____._.Material____----___-----_-_-__.____________---_________- . of com artmants_________ _ _ __Size_________________ Liquid de th._________.._ .-----------Ca acit p q p.� Capacity Disposal Fi Distance from neares w I. - ___Distance from foundation_,_-d--_-...Distance to nearest lotine-_ Number of lines------ ength of each line_____-C1--___ f.-Width of trench. -------------------- Type of filter material___ _ _�[C4rDepth of filter materia__.,�_e�_______-Total length_-_._-... ._�_-�___________ Seepage Pit: Distance to nearest well----------------------Distance from foundation______..____-_-_._.Distance to nearest lot line----------------- F-1 Number of pits----------------------Lining material..---------------------Size: Diameter_- ------Depth--------------------------------- Cesspool: Distance from nearest well__---------------Distance from foundation___- ----------- material__-__.___________.____._____-___-__ Size: Diameter--------------------------------------De th_____-.__________._ ____Liquid Capacity_ ___gal,. Privy: Distance from nearest well-------------------------------------------------Distance,from nearest building---------------_--___________.____-_ C ❑ Distance to nearest lot line----- C 4_Remodeling and/or repairing {describe}: ----- - ------- --------- --- ---------�0---------------------------------- 5Y -------------------------------------------------------------••--- --- ... -• -- ---- --• -- _.. --- --- - - -------• -----•----•---------------------•--------- ---------------------------------------- ------------------ ----------- ----------------------------------------------------- -------------------------------------------------•------------------------- --------- 1 hereby certify that I have prepared this application and that the work ill be done in accordance with San Joaquin County ordinances, State ws, nd rules and re ulations of the San J quin Local HealthDistrict. Si __- }------- ---- -----lJ-- -----� ------- --- ----�--�- (Signed) ---� --- ----- Y'- -- - -- ------ �ontractorl 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__-- -------------------------------------------------------------------- ________ REVIEWEDBY--------------------•-----------= - -------------------------------------------------------------------------------- DATE-- -------•- DATE PERMIT ISSUED------------ - - ------------ •------------ r - ----------------------------------------- Alteratia#s and/or recommendations:------- = :•--------- -------- -.-- -------•-•-•--------- -------------------•--•---•--- .F ----------I---------------------------------------------------------------------------------- --------------- --------- , - ---------------------- ------------------ --------------------------------------------------- --------------- - ------------- -------------------- - --------- -------- ---------------------------------------- ----•-------------- ------------------------------------------------------------------ r FINAL INSPECTION BY:---------------------�.......A-- - ------------- Date--------------<K_-r 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 . Revised W-2100