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t y APPLICATION FOR SANITATION PERMIT Permit No.a_. ..(! ... (Complete in Duplicate) Date Issued _ r_°Z,/ Application is hereby made to the San Joaquin Local HeaIjA District for a permit to construct and install the work herein described. This application'is made in compliance wit County Or ,irfarice No. 54?IJ JOB ADDRESS A LOCATION-._ ---- ---- / -—---------------------------------------------------------------------- Owner Na e----• ---- - " Phone ------- -� ---------------------------- --------- Address..... �+" --------- - ---------------- -- Contractor's Name---- ---- - ------- - ------ ------------------ ------ Phone-------------------------------- ---------------------------------------------------------------- -- Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court Mo�el ❑ Other ❑ ,r� Number of living units: _______ umber of bedrooms _�__ Number of baths __�___ Lot size _ ___!,1____-__�_!___�_____________________ Water Supply: Public system + Community system ❑ Privates❑ Depth to Water Table ------ ft. ti Character of soil to a depth of 3 feet Sand Gravel E:] Sandy Loam Clay Loam Clay ❑ Adobe Hardpan ❑ Previous Application Made: Yes ❑ No Sand Construction: Yes VE]o ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: u (No septic tank or cesspool permitted if public sewer is available within 200 feet. Septic Tank: Distance from nearest well_ Dist � frorr,eou anon___I __________Ma7'al -A� ---Liquid depth--------- ___---------Cy---- --No. of compartments--------- Sizer _ _ I \�11 Dispos I Field: Distance from nearest well-- ___- ---_-Distance from foundatp°n____ 1-__-_—Distance to nearest lot line---�_____ 1 Number of lines______________ Length,of each line__ ''---�__' _ t6 Width of trench_----__ __ Type of filter material_ epth of filter material_________:_ g ____________ - - ------Tota[ length --- Seepage Pit: Distance to nearest well_____-----------------Distance from foundation--------------------Distance to nearest lot line----------------- 0 Number of pits----------------------Lining material-----------------------Size: Diameter------------------------Dept h------------------.-----_-------- Cesspool: Distance from nearest well-----------------Distance from foundation-------------------.Lining material_____________________________--_____. ❑ Size: Diameter---------------------------- ---------Depth'A= Liquid Capacity gals. Privy: Distance from nearest well ___________________________________________----Distance from nearest building___-___-________________________________- Distance to nearest lot line------------ - --------------------------------------- Remodeling and/or repairing (describe):____---_____________. _ -----------------=--------------------------------------------------------------------••---------------------------------------- ----------------------------------------------------------------------•------------------------------------------------------------------------------------------------------------------------------------------------------ I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State laws, and rules and regulations of the San Joaquin Local Health District. --------------- - ----------------------------- --------------------------------------------------------------(Owner and/or Contractor) i I 11P ----------------------------------------(Title)---------------------------------------------------------------- I (Piot plan, showing size of lot, location of system in relation wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY ------- -- ----------------------------------------------------------------------------- DATE REVIEWED BY---------------------- - - -------------------------,------------------------------- DATE - BUILDING PERMIT ISS -------------------------- DATE--------- --- ------------------------------------- Alterations --- ---------•----------- Alterations and/or recommendations: _�^ j ------------•r--------------------•------------------- ---------_------------•------------------- ------------------------------ -------- ----- /v---.{�vJ�-d.,� c� i.� i s a. c s.r/� �t-r -Yr -- --------------- ------- ----�-�-- - ,, , `°c` ----------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ -------•----------------------------------------------------------------------------------------------------------------------------------=--------------------------------------------------------------------------------- FINAL INSPECTION BY:__�_`_� Sr~J� k ------------------------------------------------ Date - 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 B-51 Revised W-2100