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'2,/ _a - -t- `S-33 APPLICATION FOR SANITATION PERMIT Permit No. y (Complete in Duplicate) / ` � Date Issued r.Q'..�`� �bApplica+ion is hereby made to the San Joaquin Local Health District for a permit to construct an install ,0 k hbrein described. This application is made in compliance with County Ordinances e�No. 5 64� �t JOB ADDRESS AND LOCATION_.XI.___- ------- -- ----- --- --------- ----,Vf�n y�"---- --------------------------- Owner's Name--------- •-- ---- ---- -------------------------------- --------------------- ---- --- --U Phone-A-&� _ Address------.----- ��. .... = - --- --- ------ -- - - ---------------------------------------------•------ Contractor's Name -=�-- --- e""' Phone. / � Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel E] Other ❑ Number of living units: __ ____ Number of bedrooms.,,__ Number of baths _I__ Lot size Water Supply: Public system El Community system -Private E] Depth to Water Table .xd- ft. Character of soil to a depth of 3 feet: Sand ❑- Gravel ❑ Sandy Lo;- N'ol] Clay Loam E] Clay E] Adobe Hardpan ❑ Previous Application Made: Yes ❑ No New Construction: Yes TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tank: Distance from nearest well_-_- --Distance from f u dation____ Q Materia' ______ No, of compartments------- :_..Liquid d,pth__.__7_at p y_ ---Size Q___-� -------------Ca acit lszz Disposal Field: Distance from nearest well...... Distance foundation---cz -___ __.Distance to nearest lot line----/��____-_ Number of lines______________ _ Length of each line_______]- -.----___--.Width of trench-_-____s -�__-__- . !� ri r Type of filter material -----------------Depth of filter material-------l_�_____Total length---------,7��.____________________- Seepage Pit: Distance to nearest weft_______----_______Distance fpmWounafion___--_�d..___.Distance to nearest lot line• ttG©� Number of,pits___-__--I-.__________Lining material_ ___�_ Size: Diameter- t'�*� 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---------------------------------------:_. f ElDistance to nearest lot line--------- -------------- ----------------------"------------------------------------------------------------------------•------------------- ----------------------------------------------------•--------------------------------------------------------_---------------- ,_,Remodeling and/or repairing describe ------------------------------------------------------------------------------•---••-------------------------------------- -----------------------------------------------------'----------------------------------------- -------------------------------------4-------------------------------------------------------------------- ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- 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. w (Signed)------------ 113 -- ---- --- ------ (L"�lorerand/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]. FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY------------------------------------------------ -------------------------------------- DATE--------------- ---------- REVIEWED ----- ------ REVIEWEDBY-;-------- -------------------- ------------------------------------------------------------------------------------------- DATE------------------------------------------------------- BUILDING PERMIT ISSUED---------------------------------------- ------------------------------------------------------------ DATE--------------------- - - ------------------------------------ Alter tions,and or recommendations:------------- --------------------------------- -- -------- --- ---------- -- ---- ' p = -------------------1--- ` ------- FINAL INSPECTION BY---------- -------` --p- ----------------- 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-9-2M Revised W-2100