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APPLICATION FOR SANITATION PERMIT Permit No. ----- (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. I This application is made in compliance with County Ordinance No. 54-9. JOB-ADDRESS AND LO TION.------ '_o -------`----------------------------------------------- s --------- Owner Name-------------- --- Phone------------------------------------ Address------------------------- - Contractor's Name-------------r . �_ Phone Installation will serve: Residence Apartment House [_1Commercial F] Trailmoo er Court ❑MoteV! ❑ Other [INumber of living units: _____ Number of bedrooms _�, 'aumber of baths -_______ Lot size ___ "- --- � li ' -�---------------- ----- Water Supply: Public system ❑ '1 Community system F1Private to Water Table -------- ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ElClay F] "--Adobe and an ❑ Previous Application Made: Yes [I No ew Construction: Yes to ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: t (No septic tank or cesspool permitted if public sewer is available within 200 feet.) 1 Septic Tank: Distarce from nearest well _P_"*__Distant froipLIV �ffo ation__�_'_----___.Materia)_-_____ _______-_u ---------- No. of comportmerts_-___-. ------Size__ P �1C--57 ----Liquia depth------- -.---;- CapaciiY-----�-U�_ r.,�° r��_Q"`�_._-_-Distance to nearest lot line__ ____________ Disposal Field: Distance from nearest well__„3�____._-Distance fro3m foundatio _ Number of lines------------------- _ Length of each line____-rf�_-- Width of tr nth___ Fob _______-_"-""""" Tota{ len tIQ---- -6p Type - - p Iter material----J-f ----•- g ---6,9jT-- - 1 tante to nearest well---__r____________ __Distance from T e of filter materiaL____�__'1r.__ De t'r of filter Seepage Pit: Distance foundation-------------------.Distance to nearest lot line-____________"___ ❑ Number of pits----------------------Lining material-----------------------Size: Diameter------------------------Dept h---------------------------------- Cesspool: Distance from nearest well_________________Distance from foundation_.________________.Lining material------------------------------------- ❑ Size: Diameter-------------------------------------Depth------_--------------------------------------------- quid Ca.pacitY--.- .,-------------------gals.. may . - _ ' Distance from nearest building "rPriv� Distance from nearest well g Distance to nearest lot line------ --------------------------------------------------------------------------- - Remodeling and/or repairing (describe)-------------------- ---------------------------------------------------------------------------------------------- ----------------------------•------------------------------------------- -----------------------------------------I-------- -----------------------------------------------------------29' - ------------------------------------------------------------------------------------------------------------------------------ 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 rules and regulations of the San Joaquin Local Health District. s " " '' ------------------------------------------------------------(Owner and/or Contractor) [Signed)_ - --------------- ------� -- - ------ -- ------- - - - ------- Title---------------------------------------------------------------- k (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). I FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY------- ------ -- =A- --•------------------- ---------------------------------------- DATE • hREVIEWED BY-------------------------------------------------------- -------------------------------------------------------------------- DATE----------------------------------------------------------- BUILDING PERMIT ISSUED--------=------------ -------- ---------------- - --------------------- --------------------- ----- DATE------------------------------------------------------------- - Alterationsand/or recommendations--- ------------ ----------------------------- ----------------------- -•----------•----------------•---------------------------------------------------------- I ---------------•------------------ --------------------------••---------------------------•- -- --------------------•--------------------------------------- ------------------------- ---------------------------- ------------------------- -------------------- --------------------------------------------- ------------------------ FINAL INSPECTION BY---------1.�_j__V 77-------------- Date ..... ------Iff---1/1_/---------------------------- r SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 30D West Oak Street 132 Sycamore Street 814 North "C" Strelat Stockton, California Lodi, California Manteca, California Tracy, Califorinii ES-9-2M 8.51 Revised W-2100