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APPLICATION FOR SANITATION PERMIT Permit No. ...... 3__.... (Complete in Duplicate) /T-y Date Issued __f�__ ..______ f Applica-lion 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 Counr Ordinance No. JOB ADDRESS AND ,LOCATION------ -- ---rJ------ '-� G�------------------------------------- Owner's Name -..—r-�-- r ► w-- ------ -------------------------------------- P"o° ` '- Address----------- ..4_3-------J / ----------•-•-•- --------------------------------------------------------------------- ---------... Contractor's Name-------0_-Uv_k---cc--r77-----------------------------------------------------------------------------------------•------ Phone----------------------------------- Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: ___ Number of bedrooms _ .. Number of baths ---- Lot size ----510----)c---— _o Water Supply: Public system X Community system ❑ Private ❑ Depth to Water Table ----- ft. Character of soil to a depth of 3 et: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay.❑ Ado!66 Hardpan ❑ Previous Application Made: Yes F] No New Construction: Yes [-] No5 1 TYPE OF INSTALLATION AND SPECIFICATIONS: (Noeptic tank or cesspool permitted if public sewer is available within 200 feet.) R t 6from nearest well_________________Distance from foundation______ _ Material------------------------------------------------- LJ Tistance o. of compartments--------------------------Size----------------------------•---Liquid depth--------------------------Capacity.....------------------ Disposal Field: Distance from nearest welLA464_r—Distance from foundation_______ ----------Distance to nearest lot line___________.__. Number of lines--- Menghofeach line_____(�,_ ___._ Width of trench.._ __ -________._.XrType of filter mater ial �_ 1_C,_ f filter material---- -._.________Total length___1_ ---- ____________________ Seepage Pit: Distance to nearest well.___,,_.____________-Distance from foundation--------------------Distance to nearest lot line-___--------_____ ❑ Number of pits-----------'---- ------Lining material-----------------------Size: Diameter-----------------------Dept h___.__________________________ 1 Cesspool: Distance from nearest well-----------_-----Distance from foundation--------------------Lining material------------____.________.__________- ❑ Size: Diameter-------------------------------------Depth--------------------- -----------------------------Liquid Capacity----------------------------gals. Privy: Distance_from nearest well------____________________________.__--____.----Distance from nearest building------------------------------------------ ❑ Distance to-nearest lot line-----------------------------------------------------------------------=---------------------------------------------------------------------- m eling a y(or repairing (describe):----4� -- --- ----- - --------- ------ 41?-z------ ------ ----- ----------- --- ---------- ----•------ --•--------•---•--------------------------•---------------------------•--•----•-----•---------------------------------...-.__.--_- -- ---------- --------------------------------------------------------_...---------------------------------•--------------------------------------------------------------------------------------------------------------------------- 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 rules and regulations of the San Joaquin Local Health District. z'a✓ ✓��---- ------------------------------------------ By: Owner and/or Contractor (Signed)------------- - ----- ` -% ------------------- ( / I By:------------------------------------- J------------------------------------------------------------------------------------------(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-- -------- --------------------------- ---- REVIEWEDBY-------------------------------------------------- ---- ------------------------------------------------------ DATE BUILDING PERMIT ISSUED-------------------------=----- ---- ------•---------------•---•------------------- DATE Alterations and/or recommendations---------------------- - -•-------------•------•- a . -----------------------------------•---------------•------------------------------------- -------------------------•------------------------------------------------------------•---- - -------------------•--------------------------------------------------- --------------------------------------------- ----------------- -------------------------I-------------------------------------------------------------- ---------------------------------------------------------------•------------------------,---------------------- . ter.., •. _... S FINAL INSPECTION BY:..----- Date -------------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Streot 300 West Oak Street 132 Sycamore Street 814-North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California ES-9-2M Revised W-2100