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APPLICATION FOR SANITATION PERMIT Per No. � ..Q___� ' (Complete in Duplicate) Date Issued Applica{ion is hereby made to the'San Joaquin Local Health District fo a permit to construct and install the work herein described. ION ---1___ --- •. ----- PP P Y . This application is made in compliance with County Ordinance o. JOB ADDRESS AND LOC Owner's Name----------- .. .------- -------- ------- Phone-/ D ! ... �4 Address-----------------------•- 1 ------- ------------ --------- ---------------------- f Contractor's Name_ X --- -------------------- --- - - Phone�J'fl- .d Installation will serve: JResidenceApar+men+ House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: ___/___ Number of bedrooms --/-. Number of baths ---/-. Lot size _&Q_.-___..Y_1_4_0____-------------------- Water Supply- Public system [i--Community system ❑ Private ❑ Depth to Water Table -7'd ft. { Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe Hardpan ❑ Previous Application Made: Yes El No �ew Construction: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: F( ose tic tank cesspoolPr stwt Public.se pcavailable within 204 feet:) 5e ticF Mater` l _u-Latanceromnis+a er ' ft 2 -.-- ` -- ------- No, of compartments_____... ept .___ti2_____.__. apactyOQ----------- Disposal Field: Distance from nearest well.... _ Distance from foundation.._________.Distance to nearest lot line___p��______ Number of line's------------ _-�r_ __ Length of each line__________---------Width of trench----- ___.-._____--.--_ Depth of filter material_____ __ _ . I Type of filter i4 1159 ._ p Total length------- Seepage Pit: Distance to nearest well-----------'-______Distance from jo�unff ation_______,! -_____.Distan�� to nearest lot line�__��... . �. Number of pits-:------/___.___.__Lining material-�C__l r!"'_ .Size: Diame+er____.J_J--------_Depth----s �_________ Cesspool: Distance from nearest well-----------------Distance from foundation---------------------Lining material----------------------------------- ❑I Size: Diame+er-t-----------------------------------De th----------------•----- ------Li Liquid Capacity i p --------------------- - q --------------------------_.gals. Privy: ° Distance from nearest well-------------------------------------------------Distance from nearest building------------------------------------------ --- Y ❑� Distance' to nea.,rest lot line----------------------------- -- ---------------------------------------------------I----- ---------------- -------------------------- Remodeling and/or repairing (describe)---------------------------------------------------------- �.. i ----------.---------------------------•--•------------•----`-•---- -• ---------------•-••-----------------------•------------------------ ------1-1 ----------------------------------------•-------------- .------ --------------------------------------------------------------•------•--------------------------------------------•--•--------------- - -----------------------•------------------------- --- - ----- - I hereby certify that 1 have pre. pared this application and that the work will be done in accordance with San Joaquin County ordinances, State laws ra d rules and regulations of the San Joaquin local Health District. 1 (Signed)--------------1-- -- OLri 1-- -------- ------- -- ---=-----------------•-••----- ---------------------- ( and/or Contractor) By--------------- ,-. ------•-----------------------------------i-----•----------------(Title)-- ---------- (Plot plan, showing.size of lot, location of system in relation to wells, buildings, etc., can be-placed on reverse side). J FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY------ - -- ---------- ....4 v-, DATE + /,a . ' REVIEWED BYr� ------------ DATE- ------- --�---- ---------------------- ----------------- BUILDINGPERMIT ISSUED------------------------------------------------------------------------------------------------------ DATE----------------------------------------------.-------------- Alterations and/or recommendations:----------------- --------------------------- - ----------# ----------------------------------------•-- • -------------------------------••--- ---------•------------------------------ ----------------------------------------------------------------------------=---------------------------------------------------------:-------- -- ----- FINAL INSPECTION BY:;: Date- � SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Street 814 North "C" S}roet Stockton, California Lodi, California Manteca, California Tracy, California �/S-4-2M ; Revised W-2100