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r' APPLICATION FOR SANITATION PERMIT Permit No. - - ...5.__._.. (Complete in Duplicate) f t Date Issued Applica4-ion is hereby made to the San Joaquin Local Health District for a permitZcor, ruct and install the work herein described. This application is made in compliance with County Ordinance No. 5,4 JOB ADDRESS AND TION: -----• - - Owner's Name---,-- . -----• v Phone ..r Address ------------ ----------------------------------- Contractor's Name - = Phone_ --- ---- Installation will serve: ResidenceApartmentoff use ❑ Commercial ❑ Trailer Court'.❑-"Motel'❑ Offs r 0 i as � • Number of living units: __. __ Numiier of bedrooms _/__ Number of baths __/__ Lot size ___ Water Supply: Public system Community system ❑ Private ❑ Depth to Water Tab' eft. r m Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobq,< Hardpan'❑ Previous Application Made: •.Yes ❑ NX New Construction: Ye No E]TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank-or cesspool permitted if public sewer is available within 200 feet.) Septic Tank:- Distance from nearestwell t�tl�Distance fr m foundation __+__.Materi I_____ ___ _ ____ ___ _____ _-- No. of compartments___-±----------------SizeK---1 _*�Xr' _ Liquid depth,__ „---------Capacity_____- Q- -. Disposal Field: Distance from nearest well--.— ------Distance from foundation _ _._.Distance to nearest lot line----- 'Width ___S Number of lines______j__________________ _ Length of each line--------_ --� Width of trench._-__., _._______.__.______.-- Type of filter material _ ...___ _Depth of filter material--- "________Total length___._-_ �_�___________________ ' --- Seepa e Pit: Distance to nearest well _ .___, _____ Distance fr fo ndation_f ` l p .�___ __ .___._..Distance to nearest lot Number of pits----f---------------Lining materia Size: Diameter I Depth------ Number Cesspool: Distance from nearest well------------- ---Distance from foundation____--------------- Lining material----------------------------------- 6 El Size; Diameter------------------------------------- Depth--------------------------------------------------Liquid Capacity----------------------------gals. O Privy: Distance from nearest well-----------------------------------------------------Distance from nearest building------------------------------------------- 0 F1 Distance to nearest lot hne __11 ----------------------------- --•---------- -------------------- Remodeling and r repairing (describe):----- �� .- ' - ------ t...._.. .• •, •:;;�;�;-------------------------------•-- ----------------------------------------...... --------------------------- ......... .............. - -------- -• ------- -----------------------•---..................--•------------------------------------------------------------------------------- ------------------------------ ---- ------------------- -•-------------------=-------------------------------------------------------------------------------------------------------••---------------------------------- I hereby ce tify that I h ee prepared this�-application and that the work will be done in accordance with San Joaquin County ordinances, Sta ws, and fes a d regulatio s-o the San Joaquin Local Health District. A (Signed) wner and/_c ontractor By:--------------------- { -- -- ----------- -------------------------------------------------------------(Title)----- - - --- --------- (Plot "---(Plot plan, showing size of,locetio of system in relation to wells, buildings, etc., can be d on reversdleide}. -f: FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY------ ------- .- --- ---------------------------------- DATE----------------- REVIEWED BY------------------------------------------------ - --- _- ------- ---- DATE------------------------- -A' = BUILDINGPERMIT ISSUED-----------------------------------------------------------•-------------------------•-----------•---. DATE--------------------------- ------------•------------------•- Alterations and/or recommendations:------------ ---------------------- -------•-------?-------------------------------------------------_---------------••----••--•-------------------- ----------------------------------- ,�I ----- -�r-.4 �:�.�� "..�_., ��,�fd E ----------------------------------- -------------�-----------------d - ----------------------- ------ ------ --- ------------ -- --------- ---•-•-•---------------------------- ._ -------- ---------- �: , 44- 1- ------------------------------------------ ------------------ ------------------ --------- ---- -------------- ---------------------------------------------- - - lFINAL-INSPECTION BY:..----==4-- ----- - ------------------- 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 Revised W-2100