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APPLICATION FOR SANITATION PERMIT Permit Nlcl.� t (Complete in Duplicate) Da+e 155uedf_.l_________.__ Applica*ion 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 County Ordinance No. 5 9. .3 -,3 ------ •---------r-- JOB ADDRESS AND LOCATION______ _______ ,/ Owner's Name 1-- _f 4 *19- S,e-----ie-h-- � � 5 Phone Address---------------------------------------- '!._'ne--------------- -------------------------------------------------------------------•-•--------------------------------- Contractor's Name--------------------- ~f��- �� Phon . -- 61,f4 -7 will serve. Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: /______ Number of bedrooms.../_ Number of baths _l____ Lot size .__ '� 'Z par------ ----------- Water Supply: Public system ❑ Community system ❑ 'PrivateX Depth to Water Table ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ -Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe 9 Hardpan ❑ Previous Application Made: Yes ❑, NoX New Construction: Yes ❑ No ❑ ,f��`�� ,� TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank.or cesspool permitted if public sewer is available within 200 feet.) Septic Ta k: Distance from nearesr well_ _ _______________Distance from foundation____----_________ .Material- _ --_______________ ___-..__________._-____._---- No. of compartments--------- � ___.. Size--------------------------------Liquid depth-------------- -----------Capacity---_------------------- Disposal Field: Distance from nearest li _ . � /p..........-Distance to nearest lot line--------�'.__ �'–flistance�from foundation _ Number of lines..---I_________i_`` l ---Length of each line__�`Q -------------Width of trench--- Type of filter material___ _!y____ ____Depth of filter material---.-_ ` ______Total length_�p_'________________� __. W / * O Seepage Pit: Distance to neare t well_ QA..._------Distance fr fo ndation___.la_______.___.Distance to nearest I t line__._-________. i Number of pits.___.__._._________-Lining.material_I _Size: Diameter--3-.1"-----------Depth___ .Q___________________ Cesspool: Distance from nearest well------------------Distance from foundation-----_---__---------Lining material-------------------------- __-______ ❑ . Size: Diameter- ----- -- -----Depth----------- `----- ---- ------- ------- Liquid Capacity------- gals - „ �r :. .� - rte-- .�. Privy: Distance rom nearest we11______ .- F_____ _ ________ __________ Distance from nearest`buiidmg"__..___ ❑ Distance to nearest lot line-------- ----=---- ----- --- ------------------------------=----------------------------------------•----------- ---------------------- 0 - - - --- -•---- Remodeling and/or repairing (describe)_________________________________ ----------------`'u ------------------------------------------------------------------•--------------------------- ----------------•---------------•--------•------•--------------------------------•--------•-•-------------------------------- t . -------------------------------------------------------------••---------------.-----,-•----------------------------------------------•----------••----------•-------------------------------------------------- I hereb ertify that I hav prepared this application and that the work will be done in accordance with San Joaquin County Qr ordinance Stat laws, and,ru and regulations'of the San Joaquin Local Health District. T (Signed)---- - -- ------ ' #--- - -------------------------------_-------------------------- Contractor) By:--------------------------------------------------.- = -----------•----{Title}_ , 5 @ 4?Z� -------------- I (Plot plan, showing size of lot, location of systems relation to wells buildings, a+c., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY--------------------------- ----------------------6-.6-1---------------------------------- DATE-------------6..i_ / f-------------- REVIEWEDBY--------------------------------------------- ---------------------------------------- • ------------ DATE-------------------------------------------••-------------- BUILDINGPERMIT ISSUED-----------------------------------------I------------------------------------------------- ---- DATE-------- -------------------- -----------------------•- Alterationsand/or recommendations:------------------------------- ------------ - -------•-----------------------------------,-----•----------•---------------------•---------------------------- f ..__ Date_ = -----FINAL INSPECTION BY:. - SAN JOAQUIN LOCAL HEALTH DISTRICT l l 130 South American Street` 300 West Oak Street 132 Sycamore Street 814 North "C" Street I � Stockton, California Lodi, California Manteca, California Tracy, California _ f ES-9-21A Revised W-2100