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APPLICATION FOR SANITATION PERMIT Permit No. (Complete in Duplicate) ��J'7 Icy j 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 compliance wwiitth�CCounty Or finance o. 554499. , JOB ADDRESS AND LOCATI -------f-----I------------------ ------ -----------{�C/��I a--- -------- ---------------------------------------------------------------------- Owner's Name ------------- -------------------------- Phone---------------•-------------------- i Address------1------•-- --------- -- ------ - - - Contractor's Name- -- _ -------- - -- -- --------------------------------------------- '------------------------------------------------------------ Phone----------------------------------- Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Mot/el ❑ Other ❑ , Number of living units: ----I_ Number of bedrooms --- _ Number baths --1--- Lot size __-_ ----------------------. Water Supply: Public system E] Community system F1ivate DPrepth to Water Table -------- ft. Character of soil to a depth of 3 feet: Sand Gravel ElSandy Loam a Clay Loam ❑ Clay ❑ Adobe [HardpanE] i Previous Application Made: Yes E] No New Construction: Yes [ N0 ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public fewer is available within 200 feet.) ` Septic ank: Distance from nearest well___ _ istan e fro fouuciption___._��.------.Materi I�___ _______________ ______ _ No. of compartments--------------�_�--------Size_�_�4_�_Y.i_�-----Liquid depth-----------�----------CapacitY--��- - I v Dispos 1 Field: Distance from nearest welt-----.-r(/----Distance from foundati n.,�_r_._._t_Distance to nearest to lin � �J�� r( Number of lines__. '_____ ______ __�v.___ Length of each line___�t'Il.__°f__ Width of trench _ Type of filter mateepA of filter material--------C ___..__._-Total length--------- _ Seepage Pit: Distance to nearest well________________-----Distance from foundaFion---:----------------Distance to nearest lot line------El - Number of pits------ --------------Lining material-----------------------Size: Diameter------------------------Depth-----------------_--------------_ Cesspool: Distance from nearest well-----------------Distance from foundation.-..-_--------------Lining material-----------.------------.------------- ❑ Size: Diameter------ -r------ -----Depth--------------------- -----------------------------Liquid Capacity----------------------------gals. Privy: Distance from nearest rest well_______________ ______________________._._.._Distance from nearest building a ❑ Distance to nearest lot line = 11 Remodeling and/or repairing (describe)---------------------------------------------------------------------------------------------------------------------------- 1 ---------------•------------------------------------------------'-----------------•-----------------------------------------------------------------------------------------------•--------------------------------------- F 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. �2 - ____ '—y --- ------------- ------------------------------------------------- (Signed)--- --------------- Owner"and o ( / r Contractor) gY: ------------------------------------------------------------------------------------(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__e55�------------------------------------------------ REVIEWED BY----------------------------------- ---- DATE-------_�I- -------------------- - 16 BUILDING PERMIT ISSUED---------------------------------------------------------------------------------------------------- DATE-------------- -,�-- - -- --- Alterations and/or recommendations--------------------------------------------------------------------------------------------------------------------••-- -•------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------ -------------------------=--------------------------------- ---------------------- --------------------------------------------------------------------------------------------------------------•------------------- t ------------- ------------------------------------------------- - --- -- - -- --------------- ----- --------------------------------------------------- -------------- -- FINAL INSPECTION BY-------------- -- --- ----------------- Date-------- - -- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 Soufh American Street F300 West Oak Street 132 Sycamore-Street 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California ES---9-2M 8-51 Revised W-2100'' d