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APPLICATION FOR SANITATION PERMIT Permit No. (Complete in Dupli-Air ate) Date issued ___ _ � ..... C1�d � Application is hereby made to the San Joaquin ocal Heath District for a permit to construct and install the work herein described. This application is made in compliance with County Ordinan e No45 49 p6(— it JOB ADDRESS AND LOCATIONQ. � ---' --- ------------- - // Owner's Name T' `--=-----k L15 ---- ---------------- Phone- -------- � C} - , . Address---------------------------------------C-------`-�1---------- ----•----__---•----------•---------------------------------------------------------------------------------------------------------------- Contractor's Name--------------i----•--•---------••--------- -------• -----------r-- a Phone-----..-------•-------------------- i---------------------------- Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court L❑ Motel ❑ Other ❑ Number of living units: _1___ Number of bedrooms `3___ Number of baths _!_____ Lot size -------- ------ d______--_•-_-________ Water Supply: Public system X Community system E] Private E] Depth to Water Table -------- ft. Character of soil to a depth of 3 feet: Sand E] Gravel ❑ Sandy Loam ❑ Clay Loam El Clay ❑ AdobeX Hardpan ❑ Previous Application Made: Yes ❑ No & New Construction. Yes JXL No ❑ FHA/VA: Yes No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: I - Y (No septic tank or'cesspool permitted if public sewer is available within 200 feet.) Septic Tank: Distance from nearest well__'__''_„___Distance f rom ound,- on__ed_.______. t rial_ _ __4No. of com arments.___� _.______?: Size____`?`,CLiquid de th___MNl___._C_a_ aci_t_ P ,c-� Disposal Field: Distance from nearest weli___t-�__._.Distance from foundation 0/0 Distance to nearest lot line___ _`�______ iNumber of lines----------- ________ __ ___Length of each line__-____ v____ Width of trench_._____ _._ --------------- Typeof filter material_____ .____________._Depth of filter material Type length----------_d�_Z_______U-------------- Seepage Pif A Distance to,nearest "ll----------------------Distance from foundation--------------------Distance to nearest lot line--__---._-__-_.._ ❑ Number of pits----------------------Lining material--------_--------------Size: Diameter-----------------------Dept h--------------------------------- 4 Cesspool: Distance from nearest well----- i,_^#__.__Distance from foundation--------------______Lining material---___-------------___-._____.___. ❑ Size: Diameter-------------------------- �` -----Depth----------------------------------------------------Liquid Capacity----------------------------gals. Privy: Distance from nearest well----------- _-_---__--------------------------Distance from nearest building----------------------------------------- ❑ Distance fo nearest lot line----- ------ ------------------------------•-------------------------------------------------------------------------------------------- Remodeling and/or repairing (describe]:_!______________ -- -----------------------------------------------•---------------------------------------------------------------------------------------------- i 4 --------------------------------------------------------------------------------r-----------•--•-----------------•---•-------------------•----------------------------------------------•---------------------- ------ t� 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 Health District. 011 {Signed} 'zp ------------------------------------- --------------------- ---------(Owner and/or Contractor) ----------1--•-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-----9)-2>_ 0REVIEWED BY--------- --�---- ------------ --------------------------- DATE---•- ---------� ----y BUILDING PERMIT ISSUED-----•---------------------------------------------------------------------------------------------- DATE--------- -------------------•-:----------- ., - - "' - --- JAlterations and/or recommendations:__l-_` __-__�+.!_.--_____-5�r-"i-C:------- - ----- . _ ------ --t - -- L. �► j --t 12AI l- ---•-- - ---- ? 5------------------------------ ---------------------------------------------------------------------------- ---------------------------------------------------------------•-----•--------------------------------------------------------------------------------------------------------•----------------------•------------------------ ----------------------------------- ------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------- FINALINSPECTION BY------------------ ---------------------------------------------- Date-------------------------------- ------------------------------- --------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Street 814 Horth "C" Street Stockton, California Lodi, California Manteca, California Tracy, California ES---9-2M Revisea 1.57 F-P.CO.