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APPLICATION FOR SANITATION PERMIT Permit No. (Complete in Duplicate) Date Issued f 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 Ordinance No. 9. � JOB ADDRESS AND LO TION IQ T' --- ----------------L -------------------------------------------------------------------- Owner's Name------------(I""•S' 0 � � �1 -------- ----------------- - -- Phone-------- --------------------------- Address_ --------- - -- Address--•------------------------------ r -- AL 7............ - --•---------.._......_-------•--------------------------------------.. ------------- ------- Contractor's Name � l ^'t / ---------------' --------------------------------------------------------------- Phone----------------------------------- Installation will serve: Residence•[W Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other 1:1 Number of living units: ...f--- Number of bedrooms _I__-_ Number of baths _,f__ Lot size _f s _____________________ { Water Supply. Publics stem Community system Private De th to Water Table 1D'�_�ft- PP Y� Y ❑ Y Y ❑ � p Character of soil to a depth of 3 feet: Sand ❑ Gravel E] Sandy Loam Clay Loam El Clay ❑ Adobe❑ Hardpan ❑ # Previous Application Made: Yes E] No New Construction: Yes No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: -- '� --(No septic-tank or cesspool permitted-if public-sewer is available within,2001.feet.) -.. .,,,� Septic Tank: Distance from nearest well__60_ `7"stance f om ound ion-Jd-_�+w�.,.Mate,�ial__ _--_______- No. of compartments-_-I& _-___. ._..-�Size__�F--)��- -- ----Liquid depth--------` ----------------Capacity-----9Q-f4�--- pisposal Field: Distance from nearest well-670 "'^"`�f]istance from foundation 149 Distance to nearest lot line__` _ ~ ® Number of lines___.__ _ _. Length of each line-_---_'i�Q......___-------Width of trench.--:50,`.r__,_.___.___.___-____ Type of filter material_.�r_ ___ _ _ __ _._Depth of filter material___--1.9-.-.-_-_-_Total length------ �_________________________ Seepage Pit: Distance to nearest well----------------------Distance from foundation_.......--.---------Distance to nearest lot line_.______-_._____- 1 ❑ Number of pits---------------------Lining materia;-----------------------Size: Diameter----------------------.Depth--------------------------------- Cesspool: Distance from nearest well-----------------Distance from foundation___-----------------Lining material-------.------------------_________- Q [] Size: Diameter--------------------------------------Depth--------- -----------------------=------------------Liquid Capacity----------------------------gals. Privy: Distance from nearest well-------------------------------------------------Distance from nearest building------------------------------------------ ElDistance to nearest lot line------------------------------ -------------- - ----------------------- ------------------------------------------ -------------------- Remodelingand/or repairing (describe):------------------------------------- ---------------------------------------------------------------------------------------------------------------- --------------------------------------- -----------------------------•-•-------------------------- -------••--------------------------------------------------------------_----------------•------__-__-----------------------------------------•-•------------------------------------ + -----------------•---------------------------------.------- -----------••-•------------•----•-•------------------------------------- •---------------•-------------t-------------------------------------•------------ ------------------------------- ' -------------------•-------------•••-------------------------I--------------• ------------------------------------------------------------------I-------- --------- - 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 pules and regulations of the San Joaquin Local Health District. __-____Owner and/or Contractor)� _ a - _ — - - (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). FOR"DFPARTIvIi:NT USE ONLY f APPLICATION ACCEPTED BY----' ------ DATE--- � `.�� *7----- --------------- REVIEWED BY------------------------------------- ----------------------------------------- ---------------------------------------------- DATE------------------------------------------' ----------------- BUILDINGPERMIT ISSUED- ----------------------------------------------------------------- ---------------------------------- DATE------------------------------------------------------------- Alterations and/or recommendations:----------------- ----- - ------ -----------------------------------------------------------------------•----•-•---•------ -•-------•---------------------- --------------------------------------------- -------------------- ---------------------------------------------------------- ------------ ----------------------- ------------------------------------------------------------------------------------------------------------------- ----------------- ------------------------------•---------- - -------------- -----------------------•----------------------- ---•-----------' ' -------------------------------------------------------- FINAL INSPECTION BY:---- --- ---------- --------------------------- Date_ 1' /�—� �� y�----------------------------- 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-4-2M 145446 PTWppo 12-5n