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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 Ordina7nfV19 ------ ------ ------- E p JOB ADDRESS LOCATION--------.-,. g---C�- -- - -�- �` = -- :__ �-�'1 -------------- Owner'sPhone Name---= - -- �...�.---`�----- --- --- �-- - ---•-------------------------- :a) Adclress..�.---_4Qn---1 ...- _Ltag--- Contractor's Name - �X" �.. „'"" ------ -�------------'------------------------- Phone__ Installation will serve: Residence ❑ Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other Number of living units: -------- Number of bedrooms _.-.____ mber of baths/ of size ______________ __________.-_.------- ❑ Y ❑ " p W L Water Supply: Public system CoCommunit system Private "Depth to Water Table.l�-{eft. I Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑,t Clay ❑ Adobe[,-I�ardpan ❑ Previous Application Made: Yes ❑ No ❑ New Construction: Yes ❑ No ❑ t� ; TYPE OF INSTALLATION AND SPECIFICATIONS: 1 (No septic tank or cesspool permitted if public sewer is available within 200 fee ; Septic Tank: Distance from nearest well_401t,&.__Distance from u dation_ ._ __.__---Material__________________________ -/ ❑� No. of compartments..--�� ----------Size_fl�& +�_- --- - XLiqu, depth__L&Q�e------------Capacity-tfoo-�_ Disposal Field: Distance from nearest well ::_.__.Distancerom foufidation--------- Distance to nearest lot line---------_------- \h Number of lines----------------------------------Length of each line----------------------- • ----Width of trench--------------------- ------------- Type of filter material------ -----------Depth of filter material--------------------- Total length------..----------_---------------------- �1 Seepage Pit Distance to nearest well_ /!�.f1--c __-Distan =74 foundation___-� ---..Distance to nearest lot ii �' Number pits.._._i{___-.__._____.Lining material_ --.Size: Diameter- !�._._.Depth__�---------------- of Cesspool: Distance from nearest well________..._____Distance from foundation--------------------_Lining material------------------------------------- F1 I Size: Diameter---------------- ------- ---------Depth-------------------_------------------ --------Liquid Capacity-.--------------------------gals. Privy: Distance from nearest well-------------------------------------------------Distance from nearest building----------------------------------------- ❑ Distance to nearest lot line-----------------------------•--------------------------------------------•----------- ----------------------------------•---•----------------l�C Remodeling nd/or repairing (des ribe):.-_ �____________ __ = ------------------------• ------•-••----•----------•----------•---------------------•----------------------•----------------•----------------------------- ---------------------------------------- ___-_______. _ __-______•__________________L_____________-..__________________..______._____._______________________--..______-_.________.-.__.__.-..--_ I herebertify that I have prepared this application and t t the work will be done'in accordance with San Joaquin County ordinances, tate ws, and rules and re tions of he San Jo quin Local Health District. .. \� frac (Signed) �' tor) . . ._ i By------------------------------------------------- ' i ; ---- - ------- -------------- (Titl e)_ (Plot plan, showing.size of lot, location of system in relati to we11s, buildi s, etc., can be aced on reverse side). FOR DEPARTMENT USE ONLY APPLICATIONACCEPTED BY------------- ---------- -- ...... ------------------------ --------------------- --------- DATE (f REVIEWEDBY---------------------------------------------------- -- DATE---------- --- �1 BUILDING PERMIT ISSUED---------- •--------------------- - ------------- ---------------------------- DATE. Alterations-and/or recamm ndafions-------------- -------- --------=----- ----•-------------------- - --- ------• ----- ----------------------------------••------ - -� ---- ----- - - -- - - ----1 - - - ••- -- ----- --- -- ------------------------- �� -- �-- ' ----------�-----a�-ice-- --=--------•- ------------------- --------- --------------------- -•--------------------- ----------------------------=----------------------------------------- ------------------------------------------------ ...----- --------------------------------------------------- ' 1I ---------------------- ---------------------------- SAN INSPECTION BY:---------- ��--�'------------ -••-•------------- Date- ------------y`- t�-- 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-9-2M 145446 ATWDOP 72-54