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APPLICATION FOR SANITATION PERMIT Permit No. -_?�- 2.7- (Camplete in Duplicate) Date Issued 7,�7AI---- Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described. This applicatiori is made in compliance with County Ordinance o. 5 9. JOB ADDRESS AND TION-- - --- 14 __-----k- - - - - _----r -------------------- Owner's Name------------ ---------- Phone------------------------------------------------------•--------- Address - -- --------------------------------------- Contractor's Name----------------- -- -- - - ------------------------------------------------------------------------------------------ Phone----------------------------------- Installation will serve: Residence V?'~Apartment House [] Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: -)--- Number of bedrooms- Number of baths --A Lot sizer------------------- Water Supply: Public system 01 Community system ❑ Private ❑ Depth to Water Table . ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe AHarclpan ❑ Previous Application Made: Yes ❑ No P--*"New Construction: Yes ❑ No �PHA/VA: Yes ❑ No g+--- TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or'cesspool permitted if public sewer is available within 200 feet.) epti Tank: Distance from nearest well-----------------Distance.from foundation-------------------Material---------------_--------------------..--------_-. T No. of compartments pLiquid depth_-------------------- Capacity-...--------- ----- -- Dispos Field: Distance from nearest well------------------Distance from foundation-----f_-___------.Distance to nearest lot line-------- ------ 11 )r Number of lines------------------'_ -------------Length of each line---------a�------- Width of trench--------2•`f_�1_ Type of filter material-------------------------Depth of filter material__n__-___-_---.---Total length-_-___--16---_-_--__-_-____-__--__--__ Seepage • Distance to nearest well------'` --___Di Vice to nearest lot lin - -.-..------Distance from f ndation-�,�_�.�' . Number of pits.----1--------------Lining material__--_ -------Size: Diameter_ ________-Depth_...-��---_----____-__ AV Cesspool: Distance from nearest well----------------- Distance from foundation------------------- material______--_.__--.____------_-__-_---__ ❑ Size: Diameter--------------------------------------Depth-----_----------------------------------------------Liquid Capacity----------------------------gals. w Privy: Distance from nearest well----1---------------------------- ---------------Distance from nearest building------------------------------------------- Distance __---..---__-_----__----__------_y'-Distance to nearest lot line ---------------------•.------------------------------------------------------------------------ Remodeling and/or repairing (describe):------------- ------------------_ ___ -- ------------------------------------------------------------•--------------------------•--------------•--------•-------------•----------- ------------------------------------------------------------------------------------------- ` •---------=-------•----------•-------------------•-\----------------•--------------------------------------------------------------------------------------------. -- I --------------------------------------------------------=----------- -•----------------------------------------------------------------------------------------------------------------------------------------------------- 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 r s and regu , ions of the San Joaquin Local Health District. i i 4 SI ned { 9 --------- - - ----------- ------- -- ----- Contractor) By:-------------------------------------------------- ---- - --- --—----------------{Title)----- - - --------------------------------------- (Plot plan, showing size of lot, location system in rdmfion to wells, buildings, etc., can be placed on reverse side). ' FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY-----[-A= ---------------------------------- ------------------------------------- DATE------- REVIEWED BY------------------------------------- ----- DATE---------------------- BUILDING PERMIT ISSUED---------------------- - DATE Altera#ions and/or recommendations-----------------------•--------------------------------------------------------------------------------------•----------------•------------------------------- ---------------------------------- -------------• -------------------- -------- ---------------------------------- --------------------------------------------------------------------------------------------------- 5`----- �1 'T'� ----FEZ ------= L: -------------- ll----(-------Y-- 44------ - ----- -------------------------------- FINAL INSPECTION 1 Date - _ r5 ------------------------------------ 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 1.57 F.P.CO. ,