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APPLICATION FOR SANITATION PERMIT Permit No. .11... Z21 r (Complete in Duplicate) -• --.�..-�..-... _ Date Issued ---�----------------- Applicatian is hereby made to the San Joaquin Local Health Distr' t for, 5er to co tr�ct and ' {I the work herein described. ' This application is made in compliance ifh County Ordin nceR. JOB ADDRESS AND T14KL _ ` f ` --- -- _r. j----- - - -- --`--- ------ Owner's Name------- - - ------ --------------- -------- Address------- -------Address ----- -" -- --------------------------------------------------------- •---------------------- _ ----------- Contractor's Name -` • - y-------------- - -------------------- Phone------------------ Installation will serve:/Residence Apartment House 0 Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of t living units: Number of bedrooms&____ Numb re of,baths __,1-__ Lot size ------------------------- I! Water Supply: .Public system Community system ❑ Private ❑ Depth'to Water Table4�ft• Character of soil to a depth of 3 feet: Sand ; Gravel ❑ Sandy Loam Clay Loam E] -sClay El Adobe Hardpan ❑ Previous Application Made: Yes [:] No [ New Construction: Yes EKNo ❑ FHAVA:,Yes ❑ I [ ; { TYPE OF INSTALLATION,AND SPECIFICATIONS: ` (No septic tanVo' r'cesspool permitted if pu R sewer is available within 200 feet.) Septic Tank: Distance from nearest well__ _ �GeDisfance from foundation____jo---------M,�a al_. y No. of compartmenfs�_,---------- ------Size--- SCJ__ ------Liquid depth---..�--------------------Capaci --.-- --- III Disposy�l Field: Distance from nearest well. ______._. istance from foundation1Q____._._.Distance to nearest lot ling r-� rr r�- I L(J Number of lines---- Length of/each line_____-- �_____r _.Width of french_____ _�___ ---____ r , Type of filter material______ __________._-___ epth of filter material___.___ Total length___ __ _--____ ------------ Seepage-Pit' Distance to nearest well--------_---_--------_Distance from foundation________l._-_.___.Distance to nearest lof line____.___________ i s ❑ Number of pits----------------------Lining material____ ___o_ Size: Diameter_______________________Depth_____________---________________ Cesspool: Distance from nearest well-----------------Distance from foundation;� ______________Lining material--------------------------.___________. ❑ -----------__--------------- - qCapacity�Size: Diameter--------------------------•-----------De Depth -------------_Li Liquid Lj p ----------------------------gals. Privy: Distance from nearest well.ti._ -_-»,_ ----------------------- --Distance from nearest building------------------------------------------ ❑ .» ,_ -D.istance,Gto.rnaarest,lot-line---�_."----------------------------------------------------------------- Remodeling and/or repairing (describe):---------------------------------`------- ----------------------- --•----------------------------------------------- # I ------ .......-------- -------------- ------------------------------------------#-------=--------------------------•---------------------------------------------------------------------------------------------------------------------------.. ----------------- --------------- ------------------------------------------------ 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. Si ned I { 9 )----- -------- --- ran or Contractor) -- r -------- - --- -------- --- -------------{Title) ------- BY� = -- - - -- ---- -{ (Plot plan, showing size of lot, location of system in.relation to wells, buildings, etc., can be placed on reverse side). � t FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY-----f----------- - ZY ------------ ------- ---------------------------------------- DATE------- -------------------------- REVIEWEDBY ------------------------E----------- --- -- ---- -- ------------------------------------------- ----------------------- DATE --------- ------- ----- BUILDING PERMIT ISSUED ----------- ---------------- - DATE = --- -- Alterations and/or recommendations___________________ - f. ----------`--------------------------------------`--------- ----- ---------------------------------•------------------- --- - ------ --------- - ------ -- ------------------ An FINAL INSPECI'4QN. 'Id�'� - --------- - --- -------- Date---. _r 11 SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Streef 300 West Oak Street 132 Sycamore Street 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California ES-4-2A4 Revised 1-57 F.P.CO.