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5 ✓ 4Permit No. APPLICATION FOR SANITATION PERMIT -� It li Complefe in Duplicate) Date issuedS-- V' u `Application is hereby made to the San Joaquin Local Health District fR- ,e t to construct and install the work herein described. This application is made in compliance with County Ordinance N . 54 JOB ADDRESS AND CATION-------- ---- -------- --------- ---- :.--- -- ----------- ---- n - = Owner's Name---- �-- - ---------------- ----------- --- ---------- --------------------------- ---------------- ------ ------ 'Phone", _ �1 Address-------- -r .. �• ------------------- = ` Phone Contractor's Name--- ------------------ � . Installation will serve. Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ - Number .1 baths -J--_ Lot size __ �� -----------------=- Number of living units: _/--__ Number of bedrooms -- Water Supply: Public system (Community system .❑ Private ❑ `Depth to Water ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Ado Hardpan ❑ Previous Application Made: Yes ❑ NNew Construction: Yes�No ❑ s TYPE OF INSTALLATION AND SPECI/FICATITIONS: {; No septic tank or cesspool permitted if public sewer is available within 200 feet.) 01 Se tic Tank: p Distance from nearest well Distance from foun ation----.-- ;--.----Materi I- �'f�------------ p --------- Tank � I � ------ No. ` No. of compartments---- Size er.._�� ---��-- Liquid depth- CapaatY ----- Disposal Field: Distance from nearest well---.-____-- ---.Distance from foundation-----_-------------Distance to nearest lot line------_-.--____-. Number o-i lines-----------------------------------Length of each line____________--- Width of french----------------------------------- ❑ Type of filter material--------------------- ---Depth of filter materia4----------_-----�-------Total length--------------------- .w. " - w . . . , 41 Distance,to 'nearest lot line__. Seepage Pit:' Distance to nearest well " --Distance fr�fouation--- ----------- ___ __ ________. , Number of pits._.--/-------------Lining material -.. foundation Size: Diameter _ -� -------_ -�-.Depth--��_f-.---_-_._- 1 1 Cesspool: Distance from nearest well-----------------Distance from _._------__--- Lining materia --.- ______.______ ) Size: Diameter---------------------------- p -Liquid Capacity- ------ als. Privy: Distance from nearest well_________________ ------Distance from nearest building------------X_-------------------------- Distance to nearest lot line--- ---- .' ❑ ---- Remodeling and/or repairing (describe)------------- -- 11_ --------------------------------------------------------------------------------------------------`----------- -------------------- _----------------------------------------•-----------••------------------------------•--•--------•----•------- q - - I hereby'°certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State la ;nd r �s an regulations of the San Joaquin Local Health District. 5c ned -------------------- Y ---------- - (Owner and/or Contractor) 5 )------ - ----- w-- . : i ------- ----------------------------------(Title)- By: 7------------- (Plot plan, showing size o lot, location of system in relation to wells, buildings, etc., can be placed on reverse side].+ FOR DEPARTMENT USE ONLY f -------------- DATE------- --€ /!~--- APPLICATION ACCEPTED BY ��: QATE -- -------- = = REVIEWED BY1. DATE = ---------------------- ---- --------------- BUILDING PERMIT ISSUED-------------••------------`------------------ 1 . Alterations and/or recommendations:--.----- :'----.- --- _ 4 r l- 1 -•-----------------------------•----------------------- -----•------------- ------------- i -------------------------------------•----------------- ------------•-- -------------------------- -----;-----•---::---------------------------------------------------------•-------------------------------------- I' ;,. -------------------- -------------------- 4 FINAL INSPECTION BY:-------- -----------,�---------------- , Date- a _ .L__ `S i --------- SAN JOAQUIN LOCAL HEALTH DISTRICT 132 Sycamore Street 814 North "C" Street l30 South American Street 300 West Oak Street Manteca, California Tracy, California Stockton, California Lodi, California ES-9-2M 0-52 Revised W-2100