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r APPLICATION FOR SANITATION PERMIT Permit No..- __..__ __1-.___ (Complete in Duplicate) Date 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 complianwith Cou ty Ordinance N_ 54� KA I U44� JOB ADDRESS..AIp l_ TI -- -----------I ------------------- Owner's Name-"-- --------•-- • Phone Address...._a --- ------ ---------------- - Contractor's Name._. - -----------------==----=---- --------------------------------------------•---------------------------- Phone----------------------------------- Installation will serve: Residence [Apartment House ❑ Commercial ❑ Trail Court ❑ Motel ❑ Other ❑ Number of living units: __/__ Number of bedrooms ___ Number of baths l- __ot size_��✓�'r°----------------------- Water Supply: Public system /Community system ❑ --Private ❑ Depth to Water Table -------- ft. Character of soil to a depth of 3 feet: Sand Gravel ElSandy Loam ' Clay Loam E]Clay ❑ Adobe 00' Hardpan ❑ Previous Application Made: Yes ❑ No New Construction: Yes No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: P P P within 20Dyfew l e#'� • `�E j f P No septic tank or cesspool ermittt}d ifAxil is sL,wer is avails a of ;14 # I _ _ S'_ tic anki Distance from nearesjf wwel ___ istanae from"fou No. of compartments_.-----.--. f -----"Size _ - - .--___Liquid Oepth_'_ ---- ------" Z- ___ Capacity.! -- -------- -� . F t Dispos '1 Field: Distance from nearest we Q-_ istance from foundation;____ Distance to nearest lot lip dumber of lines_________ _ ___- _ __ �------ Length of each line ------------ f o r _ . �-__ j/_.Width of trench.______- ' ` r �_________ __________ Type of filter mafenaI__,5__ --- 4__-___Depth of filter material --------- length__-_.--J-00P________________________\n �C, Seepage Pit: 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 material --------------------------- .__._--___. ❑ Size: Diameter------------------------------ ------- Depth--------------------•--•------ --------------------Liquid Capacity ---------------------------- gals. Privy: Distance from nearest well_---- ---._____----------------------------------Distance from nearest building ._________-__________---_____--__-------.. EaDistance to nearest lot line ----- ------------------------------------------------------------------------------------------------------------ ---------------- ------ ----- Remodelingand/or repairing (describe)--------------------------------------------------------------------------------------------------- -------------------------------------------------------- •---------- ----------•------- ----------------------------------------}------------------------------------------------------------------------------ ------------------- E -------------------------------------------------- I ---------------------------___ ___________________________________________________________________________________________________________________ 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&alth District. ----- _____________(Owner and/or.Contractor) By:....------------------------------------------------------------ ----------------------------------------------------.---------------(Title)----------------------- x J-----------------------'------ } (Piot plan, showing sipe of lot location of system in relation to wells, buildings;" etc., can be placed on reverse ` FOR DEPARTMENT USE ONLY APPLICATIONACCEPTED BY ---------------------- --------------------------------------------------------- DATE--- - ---------..----- --------------------------- REVIEWED BY -------------------------------- ---------------------DATE-----------------`----------------•--•------------ ---- - - ---------------------------------------------------- BUILDINGPERMIT ISSUED------------=---------------------------- - --•---------------------------------------__ ------------ DATE---------------------�-jd-�-------------------------- Alterations and/or recommendations---------------------- �------- -------------------------------•---------------------- ------------- ----------------------- -------- ----------------------- .------------------------------------------------------------------------- . --------- ---- FINAL INSPECTION BY:. Date{ •� ----------------------------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT b 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 10-52 Revised W-2100 z