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r A ' APPLICATION FOR) SANITATION PERMIT Permit No. �- ""- - ""._ - k #: (Complete in Duplicate) / Date Issued "715'3 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 County Ordinance No. 54 - JOB ADDRESS AND LOCATION___-___:_ Owner's Name --------- � ------------------- ---------- •- Address-------------- � Phone --•__.�.___ --------- ----- -- - -• �--_--- R � -- ---- ---------- ----------------------------------••--------------------•---------------------- -- Contractor's Name"_____________________ _ - ----------- Phone_. ' Installation will serve: Residence Apartment Ho e ❑ Commercial [] Trailer Court ❑ Motel ❑ Other [] Number of living units: __- -___ Number ofbedrooms -.e._ Number of baths .-�"- Lot size __ /Q ,.��` Water Supply: Public system Community system ❑ Private ❑ Depth to Water Table;Qft- t _,Character of soil to a depth of 3 feet: Sand ❑ Gravel [] Sandy Loam El Loam Clay ❑ Adobe Hardpan [] +Previous Application Made: Yes E7 No New Construction: Yes ❑ Na�' TYPE OF INSTALLATION AND SPECIFI�TI ONS: �_ �� s" (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tank: Distance from nearest well_________________Distance from foundation------------ ----- - .Material o. of compartments --------Size------------------- -------Liquid depth------------ -- Capacity _Disposa�lyField: Distance from nearest well------------___"Distance from foundation--------------------Distance to nearest lot lino__"____._.__"""-•� � / Number of linen ---------Length of each line---------------------------._.Width Width of trench-- --------------- ---- ---- Type of filter material------------- -----------Depth of fitter material----------------""-----Total ------ length----------------•---------- - Seepa a Pi : Distance to nearest well_ r Tr �� -__ Cfistance frdm foundation_ ________"-.Distance to nearest lot line. _____ Number of pits---____-- i �• ------- Lining material- _, ------Size: iameter- - Depth.---- ------------------� Cess ool: p Distance from nearest well .1 from foundation--------------------Lining material-_-_-"_-"._------___._ ❑ Size: w Diameter-- =-------------------------------- Depth----------------------------------- -------Liquid Capacity gals. Privy: Distance from nearest i" y � well_._".".-_--....".-_______ _____________________ .__----Distance from nearest building---------------------------- El, DFstanceto earest lote -- Remodeling and/or repairing (describe):-------- � 14 ` ' ---------------------_----`--------------------------------------------------------- i •-- I {._ , _ --------•------•-------------------------------------- ------- - ------- -------------------- •--------- --•------•------•-•-----------•-------•"-----------------•------------------------`'------'----------------------•-------------------------------- - ---------_----------------------------------- --------------- F__-____--______-______________---______________-______----________________._____--_____.______-_______.__.____..__________.--_______.___.___________.....__..._ I harsh certif that I have Y Y prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State lli�, and ruled egulations of t e San Joaquin Local Health District. (Signed) - - -- ---- ---- ---- _--------t caner --O By:.- --------------------------------------------------------------{Title} :.� and/or�Con Contractor) (Plot plan, showin size'o lot, location of system in relation to wells, buildings, etc., can be pfd on reverse se}. FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY__� ` ' DATE_'-----—' -------------------------- REVIEWED BY----------------------- ---- --- --------- ------------•----------------- ----------------------------------------------------------------- DATE--- -` BUILDING PERMIT ISSUED--------- -------------------------- --------------------- - ------------------ - --------- DATE------and/or recommendations:------ "`�. ---•------------------------- ----- ---------------------------------- ----------------- --------------------------- -------------------------------------------------------- "----- ----------------------- -----------•-------- -----------------•-------------------- ----------------- FINAL INSPECTION BY:----------- f_ -"_ --------------- Date----------------•---: l� ` 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 10-52 Revised W-2100 J ,/