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APPLICATION FOR SANITATION PERMIT �` -- �( Permit No. .._7__ ----- (Complete in Duplicate) ._ Date Issued Application 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. JOB ADDRESS AND CAT N ;170 ----- -- ------ -------•- - ------------------- •-•---------------•----------- . 4 Owner's Name- Phone-------- Address---------�t 1 : Contractor's .Name----- ----------------------------------------- --------------------------= PhonX Installation will serve: Residence &_�ent House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of livi ng units: __/--- Number of bedrooms _31- Number of baths 2- Lot size ._ Water Supply: Public system unity system ❑ Private ❑ Depth to Water Table �ft. Character of soil to a depth of 3 feet: Sand F] Gravel E] Sandy Loam [:] Clay Loam ❑ Clay E] Adobe pan ❑ Previous Application Made: Yes ❑- No.jgf___New Construction: Yes TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tank: Distance from nearest well l + --Distance from foundation--_ /47----._- Mat rial--- lJo. of compartments-. .JL—-----------Size--- -_/ -. -�---Liquid depth-_._ .._ Capacity, -U��-- -- Disposal Field: Distance from nearest wel .,t..Distance from found - _-Q' ation- --_..__.Distance to pearest lo} [ `� Number of lines------- _ LA_ .Len th of,each line__.-- ' g �3" c G.S�width of trench U - --- Type of filter material ?-----'_--_Depth of filtermaterial------/0s'-__.Total length------ - ---_--------------------- Seepage Pit: Distance to nearest well_ _ Distance m fou dation-_'_,A_V___.Distance to nearest lot line__^_f___- + Number of pits.... -_--.-Lining material. __Size: Diameter-- -3_`..........Depth----2 ' Cesspool: Distance from nearest well-----------------Distance from found ation.--._.---------.----Lining material--..--_.--------______--.-._-----_-_. ❑ Size: Diameter----------°--------------------------Depth-------------------•------------- - - --------------Liquid Capacity------------ -------gals. Privy: Distance from nearest well---------___________________ -------------._.Distance from nearest building--_-.___--.__.___.______-_____--------- Q ❑ Distance to nearest lot line----------------- - ----------------------------•------------------------------------------------------------------- ------------ Remodeling and/or repairing (describe) -- - ----------- ---------1_7---------------------------------------------------------------------------------------------------------------------- ----------------------------------------------------------------------------------------------- -- ----------------------- --- -------- --------- ------ --------------------------------------------------•-----------------------------------------------------------------•---------------------------------------- I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, St a la , and–rules and- regulations of the San Joaquin Local Health District. (Signed)----- - - ------ --- -- -- - ------------------- -------------- ------------ -------------------- ----------------------------------( or Contractor) BY: --------------------------------------------------•----------------(Title)------------------------------------------- '------------------- (Plot plan, showing size of lot, location of system in relation to wells, buildings,.etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY---------------- - -- ------- ------------- --•---------------------•--------------- DATE_.-_ REVIEWED BY------------- ----- - ----------------- --------- DATE --------.-i.-- �_ ... BUILDINGPERMIT ISSUED' ..-.-•---------------------- --------------------------------------------------- ----------------• DATE----- Alterationsand/or recommendations:----------'---------- --------------- ------- -----------------------•---------------------------•------•------•---------•-----------•-----------••---------- - -------------= I------ ---------- ------------------------ = `! ------------------- -------------------------e---------I------- ------1: FINAL INSPECTION BY:.-------- ------ ------------- Date. 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 E5-9-2M 145446 ATWMqD 12.54 w