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od \P1 APPLICATION FOR SANITATION PERMIT Permit No- -_----Y' j J-- (Complete in Duplicate) Date Issued ___ft_71A 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 Or o, 5 9. . Q.__KL�*_I-.____._ --------------•--------••--•--- •-- JOB ADDRESS A O TION_Owner's Name---- --- - ------ Phone------------------- -- -:•.�__... ---•• --�-- - ----------------------_---........ - — Address. !� --------------------------------------....... --------------------------------------------------•-•-------------------- Contractor's Name--- --•---------------•---- -------------------------------------------- -- ------------------------------------ --------------------- Phone----------------------------------- Installation will serve: Residence Apartment House ❑ Commercial [] Trailer Court ❑ Motel ❑ Otherf ❑ Number of living units: ___�__- Number of bedrooms __ �._ Number of baths __'____ Lot size __ ._d__.x ��SJ _______________________ Water Supply: Public system [Community system ❑ Private ❑ Depth to Water Table Character of soil to a depth of 3 feet: Sand Gravel E] Sandy Loam E] Clay Loam L] Clay L] Adobe Hardpan E]Previous Application Made: Yes [-] .No [ New Construction: Yes D"No ❑ t TYPE OF INSTALLATION AND SPECIFICATIONS: r (No septic tank or cesspool permitted if pybli ewer is available within 200 feet.y Septic ank: Distance from nearest well&�. Distaeroo ation./.If_-----------Mater•at____ _____________ o pO�� No, of compartments-------- Size-------- ----------------Liquid dpp.th-------- Capacity Dispos Fieid: Distance from nearest ,ll50........Distance from foundati __r . _.Distance to nearest lot lin Number o1 lines--------- ------- ----------------Length of each line._-_-- -- ._--" ----.Width of trenc --------- t` --------------- Type of filter mate .� Depth of filter material_____1__ ------------Total length---------- _________________ Seepage Pit: Distance to nearest ------------------ V Seepage from foundation_------------.-------Distance to nearest lot line_______._________ ❑ Number of p;ts --------------------Lining material--------_--------------Size: Diameter--------------._...----Depth--------------------------------- O _ ,..1 Cesspool: Distance from nearest well_--------------Distance from foundation..------._--------- Lining materiaL____-____________.____._.__--__--__ Size: Diameter------------- ---- e th--------------------------------------------_------Li Liquid Capacity gals, El - Depth q p Y Privy: Distance from nearest{well _______________________-----_----_--------------Distance from nearest building-----------------.______________._____.._. ❑ Distance to nearest lot line---------------------------------------------------------------------•----------------------------------------------------- ------ Reml. d/or re airing .(d s ribe]: :._.. --------------•-- _______________________________ ••____________--_______-________________________________y-_1_______......_.-___ .________-.--___-____-_-•----_-__-_____._.______-_______-_. _. .-__________________________________--___._________________________-_.-______________---__________________________________ ________________________-_-_-_.________--__________-_________.____-__. ___-_--- 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 ofrfhe San Joaquin Local Health District. (Signed) I !-_ { r(/!.}-' :_' (Owner and/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 BY------------------------ - � DATE BUILDING PERMIT ISSUED-------------------------------------------------------------------------------------------- --------- DATE. Alterationsand/or recommendations:--------+----- ------------------------------------------------------------------•-------------- -----•----------••----------------------•-•------•- i ------------------------------------•------------------.---- ------------------------------------------------------------------------------------------------.-......---------------------------------------------------•--- ---•-•-•-------------------------------- ----- -------------- ---------------------- --------------------------------------------------------------------------------------------------------------------------------------- ------------------------- --------------- -- --- -------- --------------------------------------------------------------------------------------------------------------------------•--------------------------------------- FINAL INSPECTION BY: j /`'� Date ..... ------------------------------------------------------------- t5•S4 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 1454a6 ATWOOO 12-5a