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APPLICATION FOR SANITATION PERMIT Permit No.,—�__:5�__/__.. ! (Complete in Duplicate) S– . Date Issue -- -__ -- 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. 54 9., JOB ADDRESS D LOCAT N_.._1 /t---- ------ --------- - ----------- - ---•----- -------- ----------------------------------------------- ' s - -Pone7- Owners Name �--- ----- ----- ------------ -- - ----- --------------------------------- ---------------------------- Address.......... -- ------- --- �' --------------------------------------- Contractor's Name---- •--•-- ----------------------•----------------- ----------------- Phone------------•,------------------- Installation will serve- Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Model ❑ Other E]Number of living units: --t- 'Number of bedrooms ___I___ Number of baths ---L- Lot size ___� 1Z-_______________________________ Water Supply: Public system +[Community system ❑ Private ❑ Depth to Water Table ________ ft. Character ir of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy LClay Loam❑ Clay E] Adobe 2/Hardpan ❑ I. r Previous Application Made: Yes E] Nod New Construction: Yesoam No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted cif public se er is available within 200 feet.) Septic ank: Distance from nearest well___,_ SfQ� ista e,from ound jion_____!__D____.Materi 1_ _______________ ______ ___ __ No. of compartments_____--,-_ ._ __ __Liquid dept ______ p y_.... -----filiz� �i ----- Ca acit��jj ,�Dispos Field. Distance from nearest well _h- tance from foundation______-�r______Distance to nearest lot line7r------ -4411k __ [► Number of lines_________ ___ _ __ ___._______Length of each line-_______.__.__ tf_____.Width of french fq� l� - Type of filter materi C�' T" epth of filter material-_____/_CJ----------Total length___________ Q___ Seepage Pit: Distance to nearest well----------------------Distance from oundation-------------------Distance to nearest lot line_________________ ❑ Number of pits_`______________ _ Lining material-----------------------Size: Diameter------------------------Depth---_--------.------.------------- Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material--------------------.___________-_.._. i ❑ Size: Diameter- ------------------------------------Depth----------------------------------------------------Liquid Capacity--------------------- ------gals. F Privy: Distance from nearest well----------------------------------------------___Distance from nearest building----------_------------....-_-_._._.__-_-. E ❑ Distance to nearest lot line---------------------------------------------------------------------•------------------------------------------------------------------------ } Remodeling and/or repairing (describe)=-------------------------------------------------------------------------------------------------------------------------------------------------------- ,�- -------------------------------------------------•---•----------------------------------------------------------------- -------------------------------------------------------------•------------------------------------------------------------------------------------------------------------------------------ ---------------------------- k I hereby cert'* at I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, Stair a !, and rules and r gulations of the San,Joaquin Local Health District. ` ________Owner and/or Contractor) (Signed) --- ------ .......6 r ------------------- B ----- ----- -- --------------=---------------•-•--------------------------------------------------------------------------------(Title)---------------------------------------------------------------- (Plot plan, show 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-------- -- i BUILDI�f PERMIT ISSUED - -----------------------------------------------------•----------------------------- --- DATE----- --- Altera ions and/or decommendafiousg-------------------ry- l l ►,n { - �_ -- f _�....- --- F s ----------------------- --------------------------------------- -- ------- - --- --------------------------------------------------------- -- ---------- --------------------------•--------•--------------------------------------- f - FINAL INSPECTION BY:---.."/- ------•-----------------••-•-_--_-- ------ Date------I,,-- '> SAN JOAQUIN LOCAL HEALTH DISTRICT 5 • 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 8-51 Revised W-2100