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F Permit No. __-. .�__ APPLICATION FOR SANITATION PERMIT -__-__- (Complete in Duplicate) Date Issued --6- p i �jTA plication 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 Ordinanc o. 5 9. JOB 'ADDRESS AND TION - rte-- Q_ "_.......a.: . ', l Y Owner's Name-----------{ _1-------- ---•l}/ .- _. _7.4! R- 4------------------------ ------------------------- ------------------ ------------- ---- Address ---------------- Phone- '� �� Address-----------•- - ---------- '--------- _,S4-A4-rfr'LY--------•-------------- ------.-.------- ----------- Phone ---------- Contractor's Name .. I ---------- p l` -------------- ------------ Phone -Q r Installation will serve: Residence �D, Apartment House Commercial ❑ Trailer Court ❑ Motel [-I Other [I Number of living units: --Y--- Number of bedrooms Number of baths -ta-ter Lot size ---7-40rftX!_G'-!�_-/----------------------m Communit s stem ❑ ' I�rivate ❑ Dep toTable . . Water Supply: Public system Y Y Jr Character,of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe 9 Hardpan ❑ Previous Application Made: Yes ❑ No % New Construction: Yes ❑ No TYPE OF INSTALLATION AND SPECIFICATIONS: 1 (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tank: Distance from nearest well-----------------Distance from foundation---------------------Material-.-.-----____----.-_------------_-_-------.----. ❑ No. of compartments--------•-----------------Size--.-----------------------------Liquid depth--------------------------Capacity--------- ------------- Disposal Field: Distance from nearest well----------------_Distance from foundation------------------.-Distance to nearest lot line-----___.--.----- t �, ❑ Number of lines-------------- --------------------Length of each line------------------------------Width of trench.---------------------------------- Type of filter material-----.-------------------Depth of filter material .__---__-------------Total length---.----....------.----_-_----------------N If Seepage Pit: Distance to nearest well�__Distanc"onT, dation-40----------..Distance to nearest lot line,��'_-Number of its -Linin material__ Size: Diameter-- Depfh_ � p- - 5 Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material-----------_-------_-_----_-._------. ❑ Size: Diameter-------------------------------------Depth----------------------------------------------------Liquid Capacity-.--------------------------gals. Privy: Distance from nearest well-------------------------------------------------Distance from nearest building--..--_-----------_-_---------_---------. ❑ Distance to nearest lot line------------------------ -- --------------------------------------------------------------------------------------- ---------- Remodeling and/or repairing (describe : y f ----- ---- 1----- ---------------------------------------------------------- ��///YYY111 -----------------------------------------------------------------------------------------------------------------------------------•-------------------------------------------------------- -------- ------- I hereby certifFy t l have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State I ws, nd rules and recidlations of the San Joaquin Local Health District. (Signed)---- -•------ - ------ s .� ---- --- ------- --------- ------ r -------------- By: ----(Own /o Contractor) ----------•- ------- ---------- (Title) (Plot plan, showing size of low location of system in relatio to wel{s, buildings, etc., can be pla�e� on reverse side}. CC FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY-- - -------- -------------------------- ---------------------------------------- DATE REVIEWED BY------------------------------- - DATE-�------------------- - ------------------------ BUILDING PERMIT ISSUED------------- -�------ ------- - ------------------ BATE Alterations and/or recommendations------------------------------- ---------------------- -------- ---------------------------------------------------------------------------- ------------------------------------ --------------------------------------- ------------------------------------------------------------------ ---- - - ------------------------------------ - ------------------------------- --------------I------------------------------------------------------- J/ )J Y �Y � Date---- ----------------1 � r� FINAL INSPECTION BY--------------------------------------- �--- - ----- ----- = --------------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 Wast Oak Street 132 Sycamore Street $14 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California ES-9-2M I0-52 Revised W-2400 '�