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APPLICATION FOR SANITATION PERMIT Permit No. ..-__.. �a (Complete in Duplicate) /O Date Issued ___,. -_-/" Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work h rein descr' e . This application is made in compliance with Coun Ordin rice No. 54b, � / _�n JOB ADDRESS AN LOC T]ON--- l ;V--- - - - --------- ------------------------------------------------- ----------- -------------- --- ---4-- ---------- ---- Owner's Name------ ------ ----------- ---- --- -------- - ------------- Phone---7 ------ Address---- -----Address---- Z ----------------------------------•------------------------------------------------------------------------ Contractor's Name------- -------- --•-----A ----------•----•--•------------•------------------------------------- ------------------------------------- Phone----------------------------------- Installation will serve: Residence Apartment House ❑f Commercial ❑ Trailer Court ❑ M tel ❑ Other ❑ Number of living units: __L_ Number of bedrooms __-(_.. Number f baths _1--- Lot size -Z_y -__-____--________-- Water Supply: Public system E] Community system El Private Depth to Water Table -------- ft. Character of soil to a depth of 3 feet: Sand❑ Gravel ❑ Sandy Loam Clay Loam Clay ❑ Adobe Hardlpan E]Previous Application Made: Yes E] No L—VJ/ New Canstructian: Yes No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted ifepu4lic seww r is available within 200 feet..��,�, Septic Tank: Distance from nearest we1R`�_ __rrv--:Di t nce fro founds ion-1-0---!!'---.Mater' I ___________.__._ ._._ _ [[�7f No. of compartments----------- --t______-5i _X_ __ Liquididept --- ----- -�--- ---Capacity___-- � - + '. Dispas Field: Distance from nearest wel __ ..�____ istance from faundation�_tl _ "_Distance to nearest lot iin :r ___ ' Number of lines---------- .. _---__-___ -Length of each line------------- Q_ Width of trench_-__ .__ _-------_.______-_-- -� � 11 r Type of filter materi _ ___. ___;�' epth of filter material--------�_�_____Total length___--_.--_ --- -------------------_-- Seepage Pit: Distance to nearest well----------------------Distance from foundation___________________ Distance to nearest lot line________________( ❑ Number of pits----------------------Lining material-----------------------Size: Diameter---- -----.Depth---------------------------------� Cesspool: Distance from nearest well-----------------Distance from foundation------------------- material_______-._.___-_.___--_--_-__-______ ❑ Size: Diameter--------------------------------------Depth----------------------------------------------------Liquid Capacity----------------------------gals. Privy: Distance from nearest well----------------------------------------------- from nearest building-------------------________-________-_. ❑ Distance to nearest lot line---------------------------------- ----------r- •--------------------- Remodeling and/or repairing (describe):---------------------rr---------------------------------------------------------------------- ------------------------------------------------------ -----------------------------------------------------------------------------------------•--•----------------------------------•--------------------------------------------------------•----------------------------------- ------------------------------•------ -----------------------------------------•---------•---------------------------------------------------------------------------------------•------------------------------------------ I hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, St a laws, and rul s and reg ations of the San Joaquin Local Health District. (Signed)- - ----------------------------------------•-----------------------------------------------(Owner and/or Contractor) BYtshoing -----.... ------------------------------------------ ----------------------------------------------(Title)----------------------- --------- - ------------------------ (Plot plansize of I , location of system in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY ------- --------------------------------------------•------------------------------ DATE--�--------- ----------------------------------------- REVIEWEDBY---------------------------- - -- - -------------------------------------------------------------------- ------------- DATE----� BUILDING PERMIT ISSUED----------------------------------------------------------------------------- -------------------- DATE-----. � Alterations and/or recommendations:------------------------------------------------------------------------------- -------•------•----------------•------------------------------ -------------------------------------------------------------------------•--------------------•---•--------------•-------•----------•------------------------- ------------------------------------------------------•------------ ---------------------- --------------------------------------------------------------------------------------------------------------------------------- --------------------•---------•------------------------•-------•------------- ---------------------------------------------------------------------•---------------------------------•----------------------•--------------- ------------------ ------------------ ---------------------------- - - ---------------------------------------------------------------- FINAL INSPECTION BY------------- /,7 Date1s' ------------------------------------------ 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 f E5•—•9--2M J0-52 Revised W-2100