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APPLICATION FOR SANITATION PERMIT Permit Na. ..-. v------__ (Complete in Duplicate) Date Issued ___- Application is hereby made to the San Jgaquin Local Health District for a permit to construct and install the work herein described. This application is made in compliance wtouG}t yOrd�in'a ,No. _3 3 JOB ADDRESS AND LOCATION----I'AQ_/_IM-_awn ---------•-y G 0-i'..- --------�'----'----- t Owner's Name------- 4 f�-----" �� ///fV7- ------------- Phone//49-----Y-I'•�---4.._.._ -- � -t�� -- Address_.. ------ Wil ` =----------- .-IL,.•�-�,, �-� Contractor's Name-----r -----�--- - �i -{��-----�E--�---*------ ±�_---'_------------------------------------------------------------ - ------------------- Phone_T�'v_�-�-_��--��--- Installation will serve: Residence ❑ Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑IfA Number of living units: __'""Number of bedrooms __- Number of baths A---- Lot size ....Z4q_!----------------- Water Supply: Public system [Community system ❑ Private F1 Depth to Water Table ��ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clays„ Adobe 2• Hardpan ❑ Previous Application Made: Yes No ❑ New Construction: Yes ❑ No ❑ PHA/VA: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or'cesspool permitted if public sewer is available within 200 feet,) Sep • Ta� Distance from nearest well_________________Distance from foundation--------------------.Material------------------------------------------_-____. No. of compartments--"- - ----l---�-_----------Size-------------------------------•Liquid depth--------------------------Capacity-------------------—- Lasposal Fi Id: Distance from nearest well-__M "�'�__Distance from foundatiQ_-------Distance to nearest lot line_____ �"� Number of h es__________�_______ __ ____Length of each line___ _r__ Width of trench___e -- Type of filter material ____ ___ _____ _ Depth of filter material___"._ !�__ ____Total length/_7--------------------------------- Seepage Pit: Distance to nearest well_ ,r►�.0 _-___Distance fr f undation___________J-h- Dist n e to nearest lot line----/d_-- _� Number of pits________________Lining material___ _ �_-__-_ P .__ _--Size: Diameter______-_ �� De th___ Cesspool: Distance from nearest well----------------- from oundation"_.__________.____.Lining material__-_____"-""__-_________-_-___"______ 1] Size: iDiameter------------------------ ----------Depth----------------------------------------------- ----Liquid Capacity------------------ --- ----9111. Privy: Distance from nearest well------------------------------------------------- from nearest building___________________-___________________-. ❑ Distance to nearest lot line--------- ------------------------------------------------------------------------------------------------------------------------------------ Remodeling and/or repairing (describe):--A----3-4� 11------ - ------� �--------------------------------------- ------ - - _ --- eand •i-� -------------1-..... ----- ------. -•---- ------------------------------ -- hereby certif hat I have prepared this appl' atioat 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. (Signed)•----- ,A —k� % �T --�� Contractor) By:-------------------------------- ----------- ----------------------- ----------------------(Title --- ----------------------------------- --------- (Plot plan, showing size of lot, location of system in rel on to wells, b ilclings, etc., can be place on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY DATE.. --------- REVIEWEDBY------------------------------------- -- ---s-- - ----------------- DATE- "�_•--- -----------------.--------•------- BUILDING PERMIT ISSUED---------------------------- ------- --------- ----------- . "-.. DATE-------- ----------- Altei�atio nd/or co endations' ----- - ------------ ------ _ ---_�- ...� --•----•-------•------------------ -----•-----------------------------------------------------••-------•-------------------------•-----••---------•-------------------------------------------------------------------------------------------------------------- ----- ---------------------------------- ---------- ---- --- -------- - - - FINAL INSPECT N' BY:-- � ------------------- Date 'b fry} SAN JOAQUIN LOCAL HEALTH DISTRICT d 130 South American Street 300 West Oak street 132 Sycamore Street 814 North "C'• Street Stockton, California Lodi, California Manteca, California Tracy, California ES-4-2M , Revised 1.57 F.P,CO.