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711�� 5 APPLICATION FOR SANITATION PERMIT Permit No. _-. .._ _ a (Complete in Duplicate) Date Issued/------------ g '-----''S_ Applica{ion is hereby made to the San Joaquin Local Health District for a permit to cons u t and install the work herein described. This application is made in compiiance with County Orrdinance o- JOB ADDRESS AND LO A r�------ t 4 Owner's Name--.---- Phone Address. _ --------------- Contractor's Name-----�---------------------------- -- -------• --- -----------------I----------------------------•---------------------•------ Phon ...t/2_-1'�_ '-?_7 Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel �❑ Other ❑� Number of living units: ___ __ u er of bedrooms __umber of baths ----/-- Lot size ---�- �__c�__.�X-•---_z-s------------------- Water Supply: Public system ommunity system ❑ Private ❑ Depth to Water Table J_�ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay L m ❑ CI .y ❑ Adobe p—l-i rdpan ❑ I` Previous Application Made: Yes ❑ No ew Construction: Yes E] No El1 LJ1i TYPE OF INSTALLATION AND SPECIFICATIONS: No septic tank or cesspool permitted if public sewer is available within 200 feet.) is TWA;— , Distance from nearest well-----------------Distance from foundation-----------.--------Material_____--_--.--_--------..---__------_-----_----. Ir No. of compartments------------------- ----Size-------•------------------- --•Liquid depth--------------------------Capacity----------------------- esel�Fi Id'r�Distance from nearest well------------- _Distance from foundation--------------------Distance to nearest lot line------------ Number of lines------=------------------ ------Length of each line------------------------------Width of french............................. ------ Type of filter material-------------------------Depth of filter material-------- --------------Total length--------------------------------------_--- Seepa a Pit: Distance to nearest well---� _Distanafro foundation/ -!_.__.Di tance�to nearest lot line_ p.r'- ' Number of pits.--_ - Lining materiak � _-.Size: Diameter- .___-____Depth__o ____________ Cesspool: Distance from nearest well-----------------Distance from foundation-------------- 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):-------------------------------------------- ----------- -------------------•-•---------------------------------------•-----------•-------------------------------------------------------------------------------•---------------------------------------•--------------------------- -----------------------------------------------------------•- ---•-------------.-------.----------------•--------------------=------------------------------------------------------•----------------------------------------- I hereby-certify-that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State law�anrules and regulations W the San Joaquin Local ealth District. (Signed)-- Ik7 -----�----------- � -----------------~-- . ---- ----1A----------------------------= ontractorj By---------------------_--------------------------------------------------- - ----------- ---------------- (Plot plan, showing size of lot, location of system inreletion to wells, buildin , etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY :" APPLICATIONACCEPTED BY - ---------------------- ----- -------------- ----------------------- ----------- DATE.�------------------------------------ -- j REVIEWED BY------------------------------- - - ....... -- --------------- ----------------------------------------------------- DATE_ T' -------------------------------------------------- BUILDINGPERMIT ISSUED-------------------------------------------------------------------------------------------- --------- DATE-- Alterations and/or recommendations------------------------------------------------------------------------------------ --------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ ---------------------------------------------------------------------------------- _-----•------------------=---- --•-----------------------------------•----------•----•---------------------------------- s ----.-----•-----------•------------•----- ----•-------------------------------------- FINAL INSPECTION BY:"= t_- .------------ ------ Date----Z-�---- ----- 1 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 w Revised W-2100