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APPLICATION FOR SANITATION PERMIT Permit No. .7_. '..�-�____ DX (Complete in Duplicate) / Date Issued ---t -- Application 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. 54 } JOS ADDRESS DLO TION -�''t = ' ---:------------------------------- Owner's Name------------ ---- - ------------ - -- - --------• -- --------------------------- ------------------------ - ---- ----- - Phone--�__�_��---•--- Address--------Z- p--ca----- - l --- ------------------------------ Contractor's Name. -------------------------------------------------------------- Phone-----------------------•-• ------- Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: _._ - umber of bedrooms __1____ Number of baths .__.[-_- Lot size _6-_a__A_jZex ________________________ 1 Water Supply: Public system Community system ❑ Private ❑ Depth to Water Table -------- ft. Character of soil to a depth of 3 feet: Sand Gravel E] Sandy Loam Clay Loam E] Clay E] Adobe Hardpan ❑ Previous Application Made: Yes El No RNew Construction: Yes No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tank: iso c r4 st well_________________Distance from foundation_________________.Material--------------------------------._--_-----_---_. ❑ o. ts--------------------------Size-----•---------------------- ---Liquid depth-------------- - -------.-Capacity---------------- ------ r1 I Of Disposal Field: Distance from nearest welf_��..______Distance from foundation___._----"V 1-Distance to nearest lot line_- __________�,j Number of lines-------.___Q'"�•�____.__ ____Length of each line_______1��______A.__-__-Width of french......s' �____________________� Type of filter material-_,',��____Depth of filter material__.-._/ _-------Total length---------- ----------------------- Seepage Pit: Distance fo 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--------------------Lining material------------------------------------- ❑ Size: Diameter----- ----- --------------------------Depth-------------------.--------------------------------Liquid Capacity---------------------------gals. Privy: Distance from nearest well-----___-----------------------------------------Distance from nearest building.----------------------------------------- ❑ Distance to nearest lot line---------------------------------------------------------------------•---------------------------------------------------- ------------------- Remodeling and or repairing __-__ escribe):__ __ ,,rr ----------------------------- .-•--•- -------•----------------------- ----------------------------------------------------------------------------------------------------------------------------------------------------- --•------------------------------- -----------------------------------------------•-----------....-----------•----------------------•-----------------•------------------------- --------------------------------------------------------------------- --------- I hereby certify that I have prepared this application and that the work will be don'a in accordance with San Joaquin County ordinances, State laws, and rules and regulaattTions of the San Joaquin Local Health District. (Signed) `�'--- _— � ---=-f- ----' - ---------------------------- -------Owner and/or Contractor By: (Tale)_ (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY It APPLICATION ACCEPTED BY. .............----------------------- fie-- l------ DATE--------- / -5 REVIEWEDBY-----------------------------------------------------------------------------------•---------------------------------------- DATE------------------------------------------------------------ BUILDINGPERMIT ISSUED---•------------------------------------------------------------------------------------------------- DATE------------------ - ---------------------------...... Alterations --- Alterations and/or recommendations----------------------- ----------- ----------------------------------------•------•---------------------------•------------•-•.----- --------------- --------------------------------------------_ --------------------------------•------------------------------------------------------•-------------------------------------------------------------------- ----------------------------------------- -------------•---------------------------------- -- -----------------------------------------------------------------------------------------------------------------•-------------- -------------------------------------- ------ ------- ---•- ---- FINAL INSPECTION BY: • Date------ ------------------ - 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—q-2M 10-52 Revised W-2tGO