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r . APPLICATION FOR SANITATION PERMIT Perm% 'No. .3- (Complete in Duplicate) I J Date Issued ---f--l----- --73 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 No. 41. -- JOB ADDRESS AND LOCATION. ��-per ----------- ------ - - -------------------------------------------------------------------- Owner's Name --- -- ------------- --- ----- Phone_ __�_6 A ----------------------------------- 57 Address '= -------------------------------------------------------------------------------------------- •------------------ Contractor's Name._ ."' 1- --- ----------------------------------------------------------- ------------------------------ ---------------- Phone-------- -------------------------- Installation will serve: Residence Apartment House C y mmercial ❑ Trailer Court ❑ Motel, ❑ Other E2 J--- --- Lot size Number of living units: _ Number of bedrooms -- fl u�er of baths -- -L _ --- - ----- ---- --- ----�'-'-�- -�-- Water Supply: Public system [Community system El Private L] Depth to Water Table -------- ft. ------------ Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy LoVNo Clay Loam ❑ Clay E] Adobe [Hardpan F]i Previous Application Made: Yes E] No ER/ New Construction: Yes ❑ I TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted+f ublic sewis available within 200 feet.) Septic Tank: Distance from nearest well____ - ... �i`sta c fro union_. ___ _____ Mate ,pl___ __ _____ _____________ ___ ---------- No. __ - _ No, of compartments_-____ _: __ _- $i _ _� -------- _.Liquicl depfK._-. - -----_-Capacity_ Dispos Field: D stance from nearest w €IIt istance from foundationt:o.�`�istance to nearest lot li t___ J . �I Number of lines__________ - }ength of each line----------- Width of trench_._____ ! __ Type of filter materip ff a~ e th of filter material-__.____-�_ ---Total length____________ _�_ _____-------- Seepage Pit: Distance to nearest well _____----------------Distance from foundation------------------- Distance to nearest lot line-----..___-_-____ ❑ 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--------------------,--------------------. ❑ Distance to nearest lot line----------------- - ------ Remodeling and/or repairing [describe)------------------------------------ --------- ------------------------------•-•-----------------•----•----------- -----------••------------------------------------------------------ -----------------------------------------------------_----------------------- -------•----------------------•--------------- --------------------------- • - ----- --------•---- -----------•------------------••-----•----------•----------•---------------------------------------•------------------•---------------------------•--------------- --- ------ ... --------------------- ---------------•--------:------------•-------- ------••-----------------------------------------------•--•------------------------------_----------------------I----------------------- 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 o he San Joaquin Local Health District. (Signed)----------- _-- -- ---- --•--- -----------------------------------------------------------------------------(Owner and/or Contractor) BY:-- -----------------------------------•----------------------------------------------------------------------------------------(Title)--------- --•------------------------------------------------ (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 DAT ---------------------- REVIEWEDBY ---------------------------------------------------------------- ----- DATE__. BUILDING PERMIT ISSUED------------ -------------------- ---------- •--•••--=___-_,-____—_ - -------—DATE Alterations and/or recommendations__________ _ _____ f b ------------- ------- ------------------------------ -----------------------------------I-------------------------- -------------- ---------- --------------------------- ------------------------------------- ---•------------------------------•-------------------•---------------------------------------------------------•----------------- -------•----- -------------------------------------------------•-------- --------------------------------------------•------------------------------------------------------------------------------------------------------------ FINAL INSPECTION BY:---------- ----------------= 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 Mpnteca, California Tracy, California ES-9-2M r0-52 Revised W-2140