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APPLICATION FOR SANITATION PERMIT Permit. No. .e?_:2_(._° ' (Complete in Duplicate) Date Issued 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 . 54� g s aJOB ADDRESS AND LO N•••••. --•- ---54- -- -- ------ - -- ��-- ------- ---- Owner's s Nam _----------------------- --- - t - - ---- Phone------------------------------------ Address ------•-------------- - Address---- + Contractor's .Na a /1 .�t/kt,�F+,..�,,, i ------•---- Phone o Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ ` Number of living units: I____ umber of bedrooms __/___ Number of-baths Lot size ----.l 4___.x__t__6__O........................ Water Supply: Public system,❑ Community system Private ❑' Depth to Water Table ........ ft. .0 Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam❑ Clay Loam❑ Clay fo Adobe ' Hardpan []'i.,, ' Previous Application Made: Yes ❑ No t New Construction: YesAl No TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if-public sewer is available within 2�#ea#.) — Septic Tank: Distance from nearest well 'Td Q_ an'e from c nd o _ __-_-_.(?____-Maty*I!------------ Si l� �G!' No. of compartments---_--_-- _-- Size-! - .,Z{_, Li .depth- _ ______________Capacity_---_ -- _--- Disposal Field: Distance from nearest w ce from foundation___ o.. 1 Distance to nearest Iot Ii x Number of lines_ __.� __ ength of each line________ ......Width of trench ___.�s.__: .............. Type of filter material !-__ Depth of filter material..... _____.._Total length------- __Q------------------------ Seepage Pit: Distance to nearest well----------------------Distance from foundation________________ _-Distance to nearest lot line................. -` ❑ Number of pits------------ ------Lining material------------------T---Size: Diameter-------_---------------Depth------ ---- ------ Cesspool: Distance from nearest well...........______Distance from foundation_________ _________Lining material--------------------------------------- 0 - -_.__-__ _____-_'- _-______-❑ Size: Diameter------------------------- ------Depth--------------------------------- ----• ---------Liquid Capacity ------- -------gals. _ Privy: Distance from nearest well------------------------- -------------------Distance.frort 171 Distance to nearest lot line---•-- -_------------------------ -------------------------------------------- Remodeling -------------------- --- ---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, Sfat& laws, rules a gu tions of the San Joaquin Local Health District. V C.; (Signed) ------ _ (Owner and/or Contractor) --�E )- 6 . e - - - ----- (Plot plan, showilrsGg see of lot, location of system in relation to wells, buildings, ate.. can be placed on reverse side). F R DEPARTMENT USE ONLY APPLICATION ACCEPTED`BY------- -- -- ----------_------------- DATE REVIEWED BY ---------------------------------- - --------- ----------- DATE-.f-C -'' �` ---- - ------- BUILDING PERMIT ISSUED___ ........... _ ---------------_ --- ----_.-_- DATE- -- ----------------------- Alterations and/or recommendations:- ----- ----- ----•------------------•--- ------ --------------------- ------ - - --- --- - - ------------------- ------------------------- r l, - _. _ __•_LAK -------- ---• ! _ _________ ________� O_f _ .__.._..______.__ r FINAL INSPECTION BY-------- --- -- - ---- --_-_- Date------- - SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Street 814 North "C"Strut " Stockton, California Lodi, California Manteca, California Tracy, California ES-9-2M 8.51 Revised W-2100