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APPLICATION FOR SANITATION PERMIT Permit No. X. (Complete in Duplicate) Date Issued V . Application is hereby made to the San Joaquin Local_ This application is made in compliance with County OdBnancalth elNoc549r a permit to construct and install the work herein described, JOB ADDRESS AND LOCATION.... ' Owner's Name_----�:- - - .... ---- - --------------- -------------------------------- ------------------ Phone.A'-- _2a Address__.-1/__ .Z.-9r----------- -------I---W---- Contractor's Name___ --------------------------------------------------------------- ��...�� -- Installation will serve: Residence [A—Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: --I_--- Number of bedrooms --,2--, Number of baths __I____ Lot size ___-Ts _.7C ._�_. p Water Supply: Publics stem ----------- Y l6-Community system ❑ Private ❑ Depth to Water Table _20 ft- Character of soil to a depth of 3 feat: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe {ardpan ❑� Previous Application Made: Yes ❑ No 4--New Construction: Yes ❑ No E51 TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tank: Distance from nearest waif_________________Distance from foundation___._.---_____-_-.Material___________._____..___-. __ No. of compartments------- ------.-- Sixe --------------------- - - Liquid depth--------------------------Capacity Disposal Field: Distance from nearest welt_._----_-.----_.Distance from foundation_______________ ► �-' -.Distance to nearest lot line_______________ Number of lines_--------•------------ ------ ----Length of each line------------------------------Width of trench. Typeof filter material-------------------------Depth of filter material-----------------------Total length-:------------...--- Seepage Pit: Distance to nearest well__e• ._ Distance from foundation__-- Distance to nearest lot line__- _c �-- Number of pits---------1-----------Lining material-- Size; Diameter___-- - `� �� Depth ----- V Cesspool: Distance from nearest well _-- Distance from foundation--------------------Lining material_____.-__-_____._______- `� I ❑ Sixe: Diameter.-------------- - -------- � ------- -----------Depth- ---------------------------- Liquid Capacity ads. __ _ t _ 5 nvY=' Distance-from nearest ---------- ---------------------------Distance-frominearest building_f_-_______ ❑ Distance to nearest lot line -- r -------------- ----- --------------- Remodeling and/or repairing (describe):------------------ ---- ------------------------- 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. (Signed)----- - -- ----•----------•------ --- ---- - --------- ------- -�•�,..------ _ By:.- �r Contract ---------------------------------------------------- (Tale _ (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., canbe placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY____ ___________--- .-- - ------------ DATE REVIEWED BY-------------------------------- ---------- - - , r ------------------------------------------------- DATE-------------------------- BUlLDING PERMIT ISSUED----------•--- ---- -------- ---------- ----- ------------------------------ ------ DATE------------ -- : --------------------- terations and/or recommendations___ _____ ------------- ---------.-- ----------- ----•--_---- -------- --------------- --------------------------- FINAL INSPECTION BY:.... - = ----------------- ------------ Date-------- � ! SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Street Stockton, California 814 North "C" S+reet Lodi, California Manteca, California Tracy, California ES-9-2M 10-52 Revised W-2100