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i APPLICATION FOR SANITATION PERMIT Permit No. )li D i t C ( omplee n Duplicate)- Date Issued kApplica4ion is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described. I Ordinance No. 54 . This application is made m compliance with County Or-'roar JOB ADDRESS AN LOCATION---- Owner's Name---- - ------------ -------- - -- --- ----------------------- ----- Phone._.-------------------------------- Address-----1-7--Z- - ------ -- ------------------------- ----------•------------------ •- -....--- --- Contractor's Name----- --------------•_---------- Phone ` °> Installation will serve: Residence partment House ❑ Commercial ❑ Trailer.Court ❑ Motel ❑ Other ❑ Number of living units: -- ____ Number of bedrooms I--- Number of baths ._/___ Lot size -----074►_----X--__Ill---------------------- Water Supply: Public system4�ommunity system ❑ Private ❑ Depth to Water Table Oa- ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe�ardpan ❑ Previous Application Made: Yes ❑ No New Construction: Yes o❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) p Tank: Distance from nearest well.�.rs.__Distance from foundation__.. +6--r Material ....... NILL" o. of compartments...._.-2-.----------Size-- - -- ---Liquid depth-- r - -------------Capacity - ---_.. Septic a t Disposal FV& Distance from nearest welll?l,.C+'�--_Distance from foundation_ `1_______.Distance to nearest lot li fe____ _________ Number of lines__________ __ _ Length of each line_____2_a---------- ______Width of trench.—A-1-1_____________________ s Type or filter material___... _.. Depth of filter material----- - ------- length_____ate_________________________ ' Seepage Pit: Distance to nearest well_ Distance from foundation-_.�__f_ Distance to nearest lot line___-___-__ � ' ` / ' 1 Number of its___._- _Lining material__--�sw�.�e.__.Size: Diameter-�'�.______..____._.Depth_-a„4--•_-._______._______-_ p 7 Cesspool: Distance from:nearest well_____-----------Distance from foundation--------------------Lining material___-------------------------------------- . ❑ Size: Diameter-'-------------------- - --------------Dept#------- --------------------------------------------Liquid Capacity---------------------------gals. Privy: Distance from.nearest well-------------------------------------------------Distance from nearest building---------------------------.------------- ❑ Distance to nearest lot line-------------------------------------------------•------------------------•-------------------------------------------------------------------C x Remodeling and/or repairing (descrite):------------------------- --------------------------------------------------------------- --------•-----------------------------------------------------f ol -----------------=---•-----------------------------•-- '----------------- ------••--------•-----------------------------------------------------•-------------.-.------------- # 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. (Signed) ' i / -- ------- r Contractor) SY�---- ------ --------------------------------- Titl --------------------------------------------- ---------------- ( e1 i (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 APPLICATIONACCEPTED BY--- .I--------------------- --- ------- ---------------------------------------------------- DATE------- _ ------- ------ -------------------------- REVIEWEDBY----- - --------------------------------------------- DATE-------- i BUILDING PERMIT ISSUED i--------------------- ----------._ DATE.. --------------------------------- ---- "Altera ------ Alterations and/or recommendations------------------- ------ -`- - --------------- ------------------------------------------------------------- ...... ...... ------- ----------------------------------------- i ------- ------------------------------------------ ------------------- 1 -------------- -------------------------------------------------- - - ------------------------------------------------------- - --------------------------- ----------------------------------------------------------- ------------------------------------------------------------------ FINAL -----FINAL INSPECTION BY:.- ---- --- - ----------•------------------- Date--------------------------------- ---------- ------ --�---------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT } 130 South American Street 300 West Oak Street 132 Sycamore Street 814 Nort "C" treat Stockton, California Lodi, California Manteca, California Tracy, California E5-9"-21A 145446 PTw000 12-54