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APPLICATION FOR SANITATION PERMIT (Q Permit No. ___7___o__ (Complete in Duplicate) Date Issued Application is hereby made to the San'Joaquin Local He t a District for a permit to construcnd i the work herein described. This application is made in cam fiance with Co nt O n ce No. 54 JOB ADDRESS AN L L---- t --- ---• --- ----- --- -----�----- ------------- Owner's Name---- i_-�_. ----- ---- --- __ Phone. %_ ___-•---- Address---------- -------- ---- - - --------------- -------- - ------------------- -------- Contractor's Name------------------------- - Phone----------------------------------- Installation -------.-------_-------.-----_Installation will serve: Residence +[Apartment House ❑ Commercial ❑ Trailer.Court ❑ Mol ❑ Oth 1 ❑ Number of living units: __�____ umber of bedrooms __�_!----- Number of,baths 77I___ Lot size __ ____)it,to-_______----------------------- Water Supply: Public system Community system -1 Private ❑ Depth to Water Table ________ ft. ❑ L] E]Character of soil to a depth of 3:feet. Sand Gravel Sandy Leam Clay Loam Clay Adobe Hardpan ❑� Previous Application Made:..Yes ❑_No-/ New Construction: Yesr;o ❑ \ TYPE OF INSTALLATION,,AND SPECIFICATIONS: I {No septic tank or cesspool permitted 'f ub"c s er is available within 200 fee+.p Septic ank: Distance from nearest well_____ Distance from--```fgund tion_f D-_'_!'_""_'.Mat rjal_.._____ /T No. of compartments______ ize____ ___X_ ?_K _Liquid depth__._ _.�____ ___ ____Capacity___ Dispos I Field: Distance from nearest well._r�._ _Distance from foundation/V-_ istancelfo nearest lot liln'_� ` t! [� Number of lines__________ ____tit._---.__ --Length of each line----------------5-11____:_.Width of trench________- Type of filter materi -.Depth of filter material___.'_/_ _--------Total length___________ _ _ __ t - ' Seepage Pit: I 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 aferia -- ❑ Size: Diameter----- --------------------------------Depth----------------------------------------------------Liquid Capacity----------------------------gals. Privy: Distance from nearest well.___.___________________________________________Distance from nearest building_----_------------------------- ❑ Distance fo-nearest lot line---____---------------------------------------- Remodeling and/or repairing (describe):------------------------------------------'---------------------------------------------------- ---------------------------------- ------------------- ---------------•-----------•--------------------------- -----------------••------------•---=--------------------------------------------•-------------------------------------------I-------- -----------•------ _ __ 1 a I hereby certify that I have prepared this application and.+hat the work will be done in accordance with San Joaquin County ordinances[ State laws, and rules andWlaons of +he San Joaquin Local Health District. el (Signed)------------------ --------•------------ - ------------------------------------=------------ --------------------.(Owner and/or Contractor) By:--------------------- ------------------------ ---------------------------------------------(rifle)---------------------------------------------------------------- (Plot --- --------------------------------------(Title)---------------------------------------------------------------- (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). N '%. " --- �-- -�-w-• - -- FOR DEPARTMENT USE ONLY 'A. APPLICATION ACCEPTED BY-- ---------- ---.----- - ---- ---------- ------ --------------------------------------- DATE-�� . ----------- -------------------------- REVIEWEDBY---------------------------- --------------------------------------------------------- ---------------------- DATE----- ---- BUILDING PERMIT ISSUED-------------------------------------------------------------- -------------- ---=---------------...;. DATE------- - Alterations and/or recommendations-------------------------------- ------------------•--•----•-----------------------=------------------•---------------------------------------------------- ------•----------- ----------------------------------------------------------------------------------------------------------------------------------------------------------•----------•------------------------------------ ------------- -I ______________________________________________________________________________________________________________________________________________________________________________________________________________________________ [ � FINAL INSPECTION BY:------.--+------.` �"✓ 'ti'�� / � ------- 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 Manteca, California Tracy, California ES-4-2M 10-52 Revised W-2100