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APPLICATION FOR SANITATION P!/ ', R T 4,5 } Permit No. Q (Complete in Duplicate) ( Dat I 3 e Issued 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 Count Ordinanc No. 54 JOB ADDRESS A D LOCATION,,,_- ------------------------------------------------------------------------ - ----_-_ Owner's Name ----------------- ------------------------------------------------------------------ Phone------------•-------•-----------•--- Address-------- - .... • 6------- ------ --- ------ --------- ---•-----------------------•--.-.-_-.------•---,.------•---�-•-------"----�•--------------------------------------- Contractor's Name_._��_ ---•--------- --Contractor's Name•- - ------ -- -- --- --•------------- Phone- - Installation will serve: Residence l-l'1 Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other .(_ ❑ Number of living units: __1___ Number of bedrooms __Z_ Number of baths ___ Lot size _--�_t1____.__� �_.�--C?_____________________ Water Supply: Public system4—Community system ❑ Private ❑ Depth to Water Table S�?ft. Character of soil to a depth of.3 feet: �Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adober pan Previous Application Made:_Yes ❑--No ew Construction: Yes [_lQ_Q_:, TYPE"OF INSTALLATION AND SPECIFICATIONS: f (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tank: Distance from nearest we1IA-2lr�,�-Distance from foundation--r_- -------Material-_ _ ___ __ [ No' of compartments-------�-----------SizeS_1 _ 4/0------- depth_- �,e.........----Capacity._ ------ Disposal Field: Distance from nearest weft -LDistance from foundation___.__6_-r---Distance to nearest lot line--- 4f.�.._. ' r � r Number cf lines__________/--------_ --- Length of each line______ d___ ____Width of trench_.__-_ ________----_ Z „- Type of filter material___/ __-_/ / Depth of filter material___-.'-/9-- `___Total length_-___,67-51___`------------------------- Seepa a Pi#: Distance to nearest well:_.--x.�_ Distance from foundation__-_ �_-_.'__.Distance to nearest lot line___/_0_`___._ Number of pits___ ______________Lining material-A&A,_• &,X,____Size: Diameter____T_? -------.Depth_.-.2P_.----------------- ' f Cesspool: Distance from nearest well-----------------Distance from foundation-----..________-_..Lining material_____.._____- ____.._________________ V Size: Diameter---------------------------------------Depth-------------------------------------=------- ------Liquid Capacity---------------•-----------gals. Privy:l Distance from nearest well------------------------------_----------------'__Distance from nearest building --------------- ❑ Distance to newest lot line------------------------------------------------------ -- I. Y,Remodeling and/or repairing (describe)=-------------------------------------------------•---------------------------••--------•--•---•--•---------- F------•- . ---------------------------------------------------------•------•------.----_-•---------------•---•----------------------•-------•------•-------•-----•--••-------------------------------- 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,rand rules and regulations of the San Joaquin Local Health District. a h (Signed)---- -------------- -----•-- - =` - Contractor) l r^ r By:---- - -- ---- --- ---- z --------------------------------------------------------(Title. -------- ---- (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED,BY---------------- ------- DATE.------- REVIEWED BY - -- - DATE-------- - �._s - BUILDINGPERMIT ISSUED------------------------------- --------- -----------------•--------------------------------------- DATE----------------- a Alterations and/or recommendations:---------------------- ----- -- -----------------------------------------------------------•---•--------------------•--- - - e -------•-•--------------------------------------------------------------------------------- --------------------------------------------•---------------•-------------•--------•---------•-•-••- ------ --•-------- I ---------- ------------------------------------------------------------ ---------------------------------------'---------------------------------------•-•..---------------------------------------------------•------------- -------------------------------- -----------... t -----•-•--------------------- -'------------------ -------------4--------------------------------------- --------------------------I---------------------------------•-----------------------------•--------••--------- ` --------------- ------- FINAL INSPECTION BY--- --------- - ------------------------------------------------ Date------------------. --------- SAN -SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Street 914 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California ES-4-2M Revised W-2100 ti