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APPLICATION FOR SANITATION PERMIT Permit No. X1`. ...... U (Complete in Duplicate) Date Issued _�M_�j______ Applica+ion is hereby made to the San Joaquin Local Health Districf for permit 4o construct and install the work herein described. This application is made in compliance with County Ordinance No. S4 JOB ADDRESS AN T CATION_.____ ------ �----- --- -• -•• •-- • rte• -•--• -- -------- ------------ --- ------------•------------------------------------------- Owner's Name -----------_-_---_---_ Phone 5-6 Address - - - -------- ------------ --- Contractor's Name------- ------- ---------- w = ----`•-- ---- ----- r--------•---------•------------------------ Phone- -Qlo. b Installation will serve: Residence Apartment°House'❑''-Comrriercial`❑-Trailer Court [-]- Motel ❑ Other ❑ Number of living units: mber of.bedrooms._ Number-of-baths --/__ Lot size .___ 5`�__ S'P_f____-____..- Water Supply: Public system Community system ❑ Private [] Depth to Water Table �rff. w Character of soil to a depfh-.of 3 feet: Sand ❑ Gravel ❑= Sandy Loam ❑ 'Clay Loam ❑ Clay ❑, Adobe Hardpan ❑ Previous Application Made: Yes ❑ Nof��ew Construction:�Yes:L� FJo'❑1 TYPE OF INSTALLATION AND SPECIFICATIONS: ! (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic T Distance from nearest well O /f__Distance from.foundation_F___�-_-........Matyial_.___ ----------------------------------- -No ---- 1'�____�_�_.______- ! No. of. Com artments_____.�__ _Size_ �r6_��Xs4"' S-_Li uid de In y 14D"4" tt(1 p q p. -------------Capacit, - --- - p Number of lines_____,______. : -} Len fh of;each line=___ " A ,k-_x_~__-Disfance to nearest lot line_/-4.�______ r;f �� Dis osal eld: Distance from nearest well:A}!& -_.Disfaance from foundafio�_�_ -a- Width of trench_-st lot n___________________ Type or filter,maferial---S�_LL_Q_4_�'__�Depth of'f_ilter material__ _��__.____Total lengfh___-_ d ___________________________ i Seepage Dist anceto''nearest well--- from :foundation_,______._______.Distance to nearest lot line----S_________ d Number of pits---- ---*-"''----Lining material_ a�CCI e Size:-Diameter----_-� --------Depth-_---�°-�---------•---____-- Cesspool: Distance from neare-sf_well_,___,---- D.istance.from,foundation1------------------Lining material-_._-__.-.__________________________ Size: m -------_-•_--------=----------------- Liquid Capacity------------- ---------- -gals.Diath--- Privy: Distance from nearest well_____"�__-j_________________________________Distance from nearest bu;lding------------------------------------------ F] Distance to nearest lot line__:__`_____________----____.-- -- - Remodeling and/or repairing (describe): '------------- -------------------------------------•--------------------------------------- ---------------------------------- ----------------------------------------------------- = ----•------------•-•--------•---------------------•-•---------------------------------------- ----------------------•-------------------------------------------- ------------------------------------------------------- ------------------------------------------------------------------------------ -----------------------------------------------------------•------------------------------------------------------------------------------•-----•-----••----------------------------------- --------------•------------------------ ••-------------------•---••-----•----•--------•--••-----•-------------------------------------------------------------•------------------------------------- -------- - 1 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State l aws, and ru and regulations of the San Joaquin Local Health District. (Sign ----- !:n , and/or Contractor B Title )----- (Plot pian, showing size of lot, location of system in r ation to wells, buildings, etc., can be p act oreverse side). FOR DEPARTMENT USE ONLY ------.DATE------ .- - REVIEWED BY------ -------- ---------------- - - ----------------- ----- - DAT _;...: APPLICATION ACCEPTED BY-------- -- BUILDING PERMIT ISSUED------•--- ------ DATE------------------ -- ------------------------------------------------------ Alterations and/or.recommend ations----------- -------------------------- -- --•-- ---------------•----••......------------------•---------------------- --------•-•-- ---------------------------------------------------------------------------------------------------------------------------------------------•-----------•"---------------------------------------------•------------------- -------•-----------------•----••----------------- --------------------- -------------------------------------------------------------------------------------------------------- ------- ----------=----------------------------------------------------------------------------------------------------------------------------------------------- -------------- ---------------------------------•------------- 41 FINAL INSPECTION BY:t_;_ ----- -- _-- --------- ----------__ - Date__.-::.------:-_� !_-- - SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 30D West Oak Street 132 Sycamore Street 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California ES-9-2M ; Revised W-2100