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APPLICATION FOR SANITATION PERMIT Permit No. _ 3---7______" (Complete in Duplicate) / Dale Issued t Application is hereby made to the San Joaquin Local Healt District for a permit to construct and install the work herein described. This application is made in compliance,.with Co7X_.__X�a Or ' JOB ADDRESS A CATION ---.0 k ----- ---------------------- ----------------------- Owner's Name_C1`_ ' Phone_-`"/-0_Z- Address--s ------------- -----------------------------------------------I y----------=---......--------------•-•----------- Contractor's Name----------- ----------- --------- -- ------ ----------- _---------------------------- Phone----------------------------------- -- - Installation will serve: Residence! Apartment House ❑ Commercial ❑ Trailer Court ❑ Motyl ❑ Other Number of livingunits: __L___ umber of bedrooms I--- Number of baths ---,f--_ Lot size - �---- _ I Water Supply: Public system Community system ❑ Private ❑ Depth to Water Table -------- ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam Pr Clay Loam ❑ Clay ❑ Adobe 0/"Hardpan ❑ Previous Application Made: Yes ❑ No E?( New Construction:,Yes F .Lo( No ❑ Q TYPE OF INSTALLATION AND SPECIFICATIONS: �, 1 (No septic tank or cesspool permitted ' public sew r is available within 200 feeti) .,. , Septic ank: Distance from nearest we!I. ' scan e fron�oun tion-IY_________4-aferi_ It--- _________._____:._..__ ��(y /yJ^� X� q p ---- --- ---- Capacity t---- No. of compartments_-_...__._ ________-- - ize__ Li uid d th_- Ca acit (,! _[_Y } Distance from foundation�-�jo"_______.. istance to nearest lot line. r ' Dispos Fie4d: Distance from nearest w !I_.;_ -_. - �T""""'"'"' 19 Number of lines----------- 1�t_______ Length of each line__----___._-___ ,____._.Width of trench__ _ryry +�/ Type of filter materi _ _ , epth of filter material__._� ..______._Total length___""-__ �t�-----------__________ Seepage Pit: Distance to nearest'w'ell----------------------Distance from foundation____________________Distance to hearesf lot line______.._______" ❑ Number of pits_-----5------------------Lining material-----------------------Size: Diameter---------------- Depth------ -------------------------- 1 .1 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------------------------------------------ it lot line--:---------------------- -- ---------------------- -------•---------------------------------- ----------- ---------------- -------- ❑ Distance to neare Remodeling and/or repairing [describe)------------------------------------ ------------------------------------------------------------ ------------ 1--------------•------------------- I ------------ ------------------------------ --------------------- - t ----•---------•---------•-•-----•------------------------ ---------------------------------- ------------ ------------------------- --------•----------------------•-----------------------•----------------------------"------------------------------------------------------- --------- 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. --- a.-- __(Owner and/or Contractor' (Signed)__ . i ------------------ --- .�_ .. _ __. � --- (Title) B -~ g (Piot plan, showing size of'lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY I APPLICATION ACCEPTED BY { DATE_Sx-----------=--------------~--+------------------ ---- -------- ----------- ------------------ ._.. REVIEWED BY ----- DATE--; PERMIT ISSUED-------_------ ----------- ------ DATE V Alterations and/or recommendations---------------------- ------------- -------------------------------------- ------"-"---------------- '� ._ ------------------------------________________Y____. . Y. __-__'___--._._____._----.__.________________ ww# 4 _________________________________________________________ ------------------------------------------------------- FINAL INSPECTION BY---------------- �-!_ - c ( ------ Date---- ---------------------------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street a 300 West Oak Street .132 Sycamore Street 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California i F ES-9-2M 10-52 Revised W-2100