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Permit No. APPLICATION FOR SANITATION PERMIT ______________ (Complete in Duplicate) Date Issued _ PJAY 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, S49, JOB ADDRESS AND LOCATION----------- -3 Owner's Name C� - -`----- 'ir�,- Phone Address____:-: - -- -------------------------------------- --•--•-----------•• -- --- -•- -•---...----•---------------•----- Contractor's Name----- -a''-'z-------..----------------------------------------------------------------------------------------------------------- ------- Phone.---------------------------------- Installation will serve: Residence M Apartment House ❑ Commercial ❑ Trailer Court ❑ Mofel ❑ Other ❑ Number of living units: /-_._ Number of bedrooms r __ Number of baths /_____ Lot size ------------------ -------- Water Supply: Public system Community system ❑ Private ❑ Depth to Water Table ________ ft. Character of soil to a depth of 3 feet:' Sand ❑ Gravel L] Sandy Loam p Clay Loam 11Clay ElAdobe Hardpan E]Previous Application Made: Yes L] Nox New Construction: Yes 0 No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: ` (No septic tank or cesspool permitted if"public sewer is available within 200 feet.) , f V Dista fr fau d t€on___.____ ___ Septic Tank: Distance from nearest well_ ___ r1cp X lC ..__Ma �I______ _____-' `-' ___ Ix N compartrnenFs---- -- - ---------Size- _ --------kel.-----Liqu€d dep h------ -------------Capacity----1-0-0-0---- ( Disposal Field: Distance from nearest well____ Distance from foundati n,..__�ti__�_____ B)istance to nearest l,9t li _ _________ c ______________ _Length of each line -— __ __` __. I Number of.lines__________4:g ___ _ Width of trench_____ --____ Type of filter materia _ �epth of filter material--------/_S___ Total length-------- . --- -------------------- Seepage Pit: Distance to nearest well----------------------Distance from foundation--------------------Distance to nearest lot line--- -------------- ❑ Number of pits----------------------Lining material__ Size: Diameter-----------------------Depth-----_-_____-_______--__________ Cesspool: Distance from nearest well-----------------Distance from foundation-------------------.Lining material_____________________________________. ❑ Size: Diameter----------------------------- Depth-------- -------------------------------------------Liquid Capacity-------------.--------------gals. Priv Distance from nearest'well ------------------------------Distance from nearest building------------------------------------------ ❑ Distance to nearest lot fire----------------------------------------------- - .— 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 Count ordinances, State laws, and rules and regulations of the San Joaquin Local Health District. d (Signed)-- ei�..dltsr'��------c..#?_�T7--------------------- -- --------------------------------------------------------------________(Owner and/or Contractor) k 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- ----- -- --------------------------------------------------------------------------•---- DAT --------------------------------------------- 11-: ------ �, REVIEWED BY----------- -- - DAT BUILDING PERMIT ISSUED---------------------------------------------------------------------------------------------------- DATE------ Alterations and/or recommendations:_ ------------------ -------------------------------- I i ___________________________________________________________________________________ ________________________________________ I f ------------------------------------------------- -------------------------------------------------------------------------------------------------------------- ------------------------------- ------�-------------- --------------------- -------------- FINAL INSPECTION BY:----------- ------------- ------ Date------------- v �-� 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 8-51 Revised W-2100