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APPLICATION FOR SANITATION PERMIT Permit No. (Complete in Duplicate) Date Issued 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. 9. JOB ADDRESS AND LOCAT ON--/ -!_:/_-vZ' �' ------------------ / � Owner's Name---------- ----•• •- --•.................P�� ---- --- ---- ---- ----- P ne---------------------------_----- P - p �5-------� ��--- •-•------------------ • Contractor's Name----- --- ---- ------------------------------------------- ------------------------------------------------------------ - Phone................................... Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: .1---- Number of bedrooms ---/-. Number of baths ..../_ Lot size ------b-522---X_t-0_Q__________________ Water Supply: Public system El Community system Private E] Depth to Water Table-I j Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay IX Adobe❑ Hardpan ❑ Previous Application Made: Yes ❑ NoA New Construction: Yes � No E] TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) - Septic Tank: --Distance from nearest well_J.Q0Q----Distan a from found tion....Q.........—Mat rials_ ?2� - ('� No. of compartments_-.--A----------------Size__�,��_.X__�.Liquid depth_-._--�.._��j.Capacity___�e.V' ...... a Disposal Field: Distance from nearest welI)D._CC;?_Distance from foundatipp_.__�_.Lz - Distance to nearest lot line.....__ - Number of lines___.__'.'�/__._.____.______ _ Length of each line__�_Q-_r.-_... _�_�Width of trench.__ ._.�__.�............... Type of filter material___.3Ty` Depth of filter material-------/R.Y_.__Total length........ ........................... Seepage Pit: Distance to nearest well-------_--------------Distance from foundation__--_____--_-•...__.Distance to nearest lot line----------------- F1 Number of pits------------- ------Lining material-----------------------Size: Diameter-----------------------Depth-.-------------------------_--- 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------------------------------------------ R __-__ -.-.-_--. --•- _-__-___-_-_.❑ Distance to nearest lot line-------- --------------------•----------------------------------------------------.-----------------------------------------------•----------- Remodelingand/or repairing (describe) ----------- --------------------- ------------------------•-------------------------------........................................................ ---•-•----•-----------------------------------------------•--•-------------------------------------------.---------------------=-----------------•------------------------------------------------------------------------- ------------------------------------------------------•-----------------------------------------------------------------------------------------•---------------------------------------------------..----------------- ------•-----•---------•....----•-•-----•---•--••-------••-••--•--------•------------------••••--------------------•---•---•••-------------------------------•-- -•---------•-•--••-•------•----------------------------------- �O 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 rule and regulations of the San Joaquin Local Health District. A (Signed) � ------------------------------------ -- Owner and/or Contractor rZA By: --- .. -------------- --------------•---(Title)--------------------------------------------- --------------- (Plot plan, showing si of lot, location of system i �Iaon t wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATIONACCEPTED BY------ --------------- ------- -------------- ---------------------------------------------------- DATE..............................--------_-------------- REVIEWED ---- _-------------- REVIEWED BY----------------------------------------------------- ---- ----- ------ - ` , �► ------------ DATE----------} y � �� . .... BUILDINGPERMIT ISSUED-------------------------------------------------- ---- - --------• DATE............................------------- _-_------------ Alterations and/or recommendations:__---------_----------- -------- ---------- - ..............................................-.............................. ---------------------------------------- ----------------------------------------------- -------------I............ --•-----------•----------- ------------------------•---------•••--•-•--------......---•---••-------------- FINAL INSPECTION BY:.................. . -C1.. Date----- -_._ -_ _.--. --------------------- 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 145446 ATWOOD