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APPLICATION FOR SANITATION PERMIT Permit No. ---_:--------.•--_--.-. (Complete in Duplicate) Date Issued .----------- - 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 Ordinance No. �• + � 2 r' -----------------------;----------•----------------------------------- JOB ADDRESS AND L CAT10N___:._ _ -------- - ---------------""" € / v Phone -- ---- Owner's Nae - - � --------------------- ------------- m - 0 Z— ' SI0� 6-11 - ------------------- ----------- - Address------------ •-----------=----- . - �--------:mow ,-;----•`•-�--.,..,�--- ---- -- --- ------------------- ------ Phone----•--•--------------------------- Contractor s Name," __=."" ��'•' Installation will serve: 'Residencey r, ti ' f [� Apartment Hou ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other � I Number of livin units: 4"'__ Number of be _J" Number of baths __.hoot size ____"________ __ Water Supply: Public system'❑ Community system '❑ Private Depth to Water Table ,__"____ ft. Character of soil to a .epth of 3"feet —Sand Gravel 171 Sandy Loam El Clay Loam ❑ Clay El Adobe�ardpan ❑ i jPrevious Application Mader Yes-0- { New Construction: Yes [�No ❑ TYPE OF INSTALLATION=AND SPECIFICATIONS: (No septic tank or cesspgol permitted if public sgwer is available within 200 feet.) _ p ,. _ .. .. , 'well ' e th - _- Q --._ Mater 'n k: Distance from nearest well __ -"___Distancepfrom fours a�ion__.___ _.____ � "Capacity. Septic T " w.., .., :Na of compartments Size Liquid d p,� -in- Dispos Field: � Distance from nearest�eil'_"'_�.!�_�_-. _.Distarite'from`foundation__"�,-f-..----Disfiance to nearest lot line__ti___ + Number;of lines--f---= ength of each line------------------- Width of trench '`7------------ Type of filter material. :___ _ ___ f'R6th of filter material-------- ----------Total length-_'---------leo---------------- - Seepage Pit: Distance to nearestwe ------ from foundation_..____.____.____..Distance fio nearest lot line_________________ ,. P _-- Distance from foundation-------------------Lining materi'Ptn--------------------------------- ❑ mbar.of is--,:= ------ -- ---- Linin material----------------------- ixe: Diameter----------------------- Cesspool: Distance from nearest well'- _Li Liquid Ca ac Size: Diameter._..'. '------------•- ---Depth-----------------------=----------=--------- q P ktY gals. El to nearest lot line--=--------'------------- ----------- Distance from nearest building------------------------------------ f Privy:; Distance from nearest well-----__ -- -- --_---" - - ❑ - f• �• -�- Distance ------------- Remodeling and/or repairing {describe):------------------ --- ! s - "-•---------------------•----------------------------- •----------------------------- ----- _ 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. }� C Cx '-----------------.' a� fi ------------------------------------------------------- (Signed) caner an r an �O and/or tractor) ------- 7 Sy € --- --- -- --- -- - (Title) ` Plot Ian. showing site of lat;.location of system in relation to wells, buildings, etc., can be placed on reverse side). R FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY___ -- DATE------ 7------------------------•----------------------- DATE " - REVIEWED BY - ---- -- - ------------------------------------------------------- --------- --------------------------- BUILDING PERMIT ISSUED---------- -------- --��Z�..------- -------------------------------------------------- DATE - ------------ Alterations and/or recommendations:------------------------------ ---------•-----------------------•-•- -------------------------------------------------- -------------------------------------------------------------------------------------------- ----------------------- .. -------- Date---------- ------------ --------------------------------- FINAL INSPECTION BY.. ---------.----------------- 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-4-2M Revised W-2100