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6 Y Vc APPLICATION FOR SANITATION PERMIT P mNo. (Complete in Duplicate) 162-1 -x!-IJ-w Date Issued r Application is hereby made to the San Joaquin Local Health District for a permit to const�uct`ar)r� install thin work herein described. This application is made in compliance with County S1inance o/& JOB ADDRESS ARP LOC ION_ - 1 --- - ------------------- -------------------------------------------------------- Owner's Name � ---- -- ---- ----`----�,---`-----�---------------------- Phone------------------------------------ - l Address__...----Z-&. -s-------------- - ......I/ -------------------------------------------- -------------------------------------------------------------- ----,-,------ -- - Contractor's Name --- Phone Installation will serve: Residence [t��Apartment House ❑ Commercial ❑ Trailer Court Motel ❑ Other ❑ 1 Number of living units: ___I___ Number of bedrooms __ Number of baths ___I-__ Lot siz _ -_-_�-�--�-----f--�[----------- Water Supply: Public system Community system ❑ Private ❑ Depth to Water Tableal - ft. Character of soil to a depth of 3 feet: Sand Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay E] Adobe Hardpan E]Previous Application Made: Yes F1 No 5New Construction: Yes Z No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public s?wer is available within 200 feet.) 110 !► __Distance from foundation___' 77 i Septic ank: Distance from nearest well__�� _1u______--.Material__st�______--'.'�__�_______ -------Liquid depth-------------------------Capacity-- �{ No. of compartments-------------- --- --Size-------.-_-------_-_-_ ['�'' �/ - Dispos Field: Distance from nearest well____SS -__Distance from foundation-----L.[_-----------Distance to nearest lot line----��______- Number of iires_________-__ Length of each line_______ __--__ Width of trench___.-_X 4"____________________ r h"x' ,l-- , ! Type of filter material:_______w__>:�n/,_:.,�.rDepth of filter material-------- length__��_x�_________________- 5eepa Pit: Distance to nearest w l{__-I.1!_V_________Distance/�o and ion_- 1 -___.D,j t nr�e to nearest lof li�je_- ____— Number of pits----------f---------Lining material___Slt t Diameter--__ �__ ____Dept h_________ZIE------_t=�., Cesspool: Distance from nearest well-----------------Distance from foundation----------------.-_Lining material________--____________-________----_. V� ❑ Size: Diameter--------------------------------------Depth----------------------------------------------------Liquid Capacity----------------------------gals. Privy: Distance from nearest well------------------------------------------------_Distance from nearest building------------------------------------------ F-1 Distance to nearest lot line---------------------------------------------------------------------------------------------------------------------------------------------- V Remodelingand/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 Ia , and �les andfiregulations of the San Joaquin Local Health District. . i ! c Owner and/or Contractor (Signed), _ -------- { / ) By:-------------------------------------------------------------------------------------------------------------------------------------(Title)---------------------------------------------------------------- (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 APPLICATIONACCEPTED BY ------------------------------------------------------------------------ - DATE-P' ---------------------------------------------------- REVIEWEDBY ------ --------- ---------------------------------------------------------------------------------------- DATE--Lp--------------------------------------------------- BUILDINGPERMIT ISSUED----------------------------------------------------------------------------------------------------- DATE------- ------------------------- -------------------- Alterationsand/or recommendations:----------------------------- -------------------- --—------------------------------------------------------------------------------------------------------ ---------------------------------------------------- ----`----- ----------- - ---:r- - - - - --- - ---- ---- - ---------- --- _ r+ C a - •>< .. ,.== -------------------------------- ---------- ------ - - - - ---- --- ----- -- ---------- --------------------------- ---------------------------------------------------------------------------------------------------------=------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------ --------- ---------------------------------------------------------------------------------------------------- FINAL -- -----------------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-9-2M 8-51 Revised W-2100