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APPLICATION FOR SANITATION PERMIT Permit No. ---'�__---__---- (Complete in Duplicate) Date Issued ._`I_'1V��?_b_ 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, 5 9. JOB ADDRESS AND LOCATION-------.-. Jam_ ��.�---------------- - _ / ---•----------------------------------------•-- Owner's Name-------- _ --•--- ------------------ - ---------------------------------------- Phone--------------------- • ----•--- ---- Address-•- ....�..---_ -t' Contractor's Name._..__ .. --- ----•`[♦ = --------------------•------•------- Phone----------------------------------- 4 Installation will serve: Residence Apar+ment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: _ ---_- Number of bedrooms __; Number of baths --f/-- Lot size ____s`.7� _ Q -- Water Supply: Public system 'R Community system El Private ❑ Depth to Water Table -------- ft. Character of soil to a depth of 3 feet: -Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe -Hardpan ❑ Previous Application Made: Yes ❑ No ®_ New Construction: Yes ❑ No 21', 5 TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tank: - _j-Distance from nearest well------------------Distance from foundation--------------------Material------------------------------------------.__-_-. ❑ compartments- ------- ---------------Size------------------------•-------Liquid depth--------------------- ----Capacity-------------------- Disposal Field: , Distance from nearest well.................Distance from foundation---___-.___.__.-_Distance to nearest lot line------------------ ❑ ;a�5"- er of lines----------------------------------Length of each line---.---•-----------------------Width of trench------------•------------.----- Type of filter material-------------------------Depth of filter material---------- .....--.--.Total length---.__•-•--------------------------------- Seepage Pit: Distance to nearest well-._-,/!/A--A--t�-istance from f unciation- ---------Distance to nearest lot 14e __.__._. Number of pits.----/-------- --Lining material-K.—�. .-.-- .4qe- Diameter_-- :5r-3_------Depth--------------------------------- Cesspool: Distance from nearest well-----------------Distance from foundation...........-------- Lining material........._.__.-..__-__-_-_---------- \ ❑ Size: Diameter------------------------- ----- ----Depth----------------------------- ---- - --------r------Liquid Capacity----------------------------gals. Privy:: Distance from nearest well-------------------------------------------------Distance from nearest building------------------------------------------ ❑ Distance to nearest lot'line------------------- --------------------------------------------- -------------•--------- -------------------------------- ------------ Remodeling and/or repairing (describe):------------------------------------- -------------------------------------••--•---------------•----••-------------•-----------•------••------------- - ------------ ---------- ----- •----------------------------•---------- ------...-------------------------•---------------------------------------------------------------------------•---------------------- I hereby cer ify that 1 have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, S e ws, and rules and regulations of the San Joaquin Local Health District. (Signed)........... -------- �' ' Y --------------------------------------------- -------------(Ow er and/or Contract BY: - (Ti+le) -�---------- ---------------------- ----------------- J (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). I FOR DEPARTMENT USE ONLY f APPLICATION ACCEPTED BY------------- --- -- -•------------- DATE-- -------- --------------------------- -- - REVIEWEDBY-------------------------------------------------- --- ------------------------------ - ------ ------------------------- DATE------ ----- _ -�-----•-----------------------•---•-------- BUILDING PERMIT ISSUED-------------- DATE--------- Alterations and/or recommendations:- - ----------- ------ - -------------------------------------•----•----------------- --•-•••-- -- -------.. ----------- ---- ------ �---•-•---•--------------- - - ----- ----------------------------- ----•------------- ------ - --------------------- -- ----------------------------------- -------------------------------- ------- ----------- -------..-.-...---------------- . ------ --------------------- Date- �----�----" ---- - ------------ --- FINAL INSPECTION BY:...........:-�:---.`'� ------------- � SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street .132 Sycamore Sfreet 014 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California ES-9-2M 145445 ATWQOD 12-54