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2, ( � APPLICATION FOR SANITATION PERMIT Permit No.��- o...`.........:"" (Complete in Duplicate) Date Issued7:�__Zn45 Application i y made to the San Joaquin Local Health District for a permit construct and install the work herein described. This application is made in compliance with CountyOrdinanceNo. 54 JOB ADDRESS AND LOCATION_ d ---- PN, / --------------------- -- Owner's Name---------- ------------- Phone---- -- Address � Q --- •--•--- ---------------------------- ;F- Contractor's Name-------------------------- el - ------ Phone................................... Installation will serve: Residence ApartKent House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units:__'----- Number of bedrooms ----L Number of baths ----L Lot size ....... ----------------------- Water Supply: Public system ❑ Community system X Private ❑ Depth to Water Table .9-0__ ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay Adobe❑ Hardpan ❑ Previous Application Made: Yes ❑ No 0( New Construction: Yesx No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if pblic sewer is available within 200 feet.) --A— Sep is Tank: Distance from nearest well.. _"Distance ifroound�n__-_--I.r.Material ------------- ��}} :_. No, of compartments..____ _.____11 /�� __Size._..__ ,X_�._Liquid de�pylth_____.._____ CapaQ Dispo al Field: Distance from nearest well__�.O7 Distance from foundation.... __J----Distance to nearest lot Number of lines---------; -___.. _. _ Length of each line.._-3.0---�__3..0..Width of french...... .�------------------- \ Type of filter material....S.—fi-P-CADepth of filter material------- -$-- ----Total length.......1p..0......................... Seepage Pit: Distance to nearest well----------------------Distance from foundation....................Distance to nearest lot line____-_.--_-_----- O ❑ Number of pits----------------------Lining material------------------_----Size: Diameter-----------------------Dept h--.-----.-----------.---.-------- 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--------------------------------------------------------------------------------------_-------------------------------------------------- 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 County ordinances, State laws, and ruleWid regulations of the San Joaquin Local Health District. (Signed)- - `� !' ---- (---------J----------------------------------------------------------------------------- ------(Owner and/or Contractor) By:------------------------------------------------------------------------------------------------------------------------------------(riifle)------ --------------------------------------------------------- (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:-----------_-------- ------------------------------------------------•-------------------------------------------------------............................... -------------------------------•---•----------------•----------------------------------------.........---------------------•-----•-•-----------........................................................................ -----------------------------------------------------------------------------------------=--------------------------------------------------- -------------------------------------------------------------------------------- -------4y - FINAL INSPECTION BY------------------- •----------------------------- Date------------ ---_q.-- 20_ 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 0-52 Revised W-2100