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V 4Z -t t APPLICATION FOR SANITATION PERMIT Permit No. ..... r 1 11 1J" (Complete in Duplicate) Date Issued/! -_ • f 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 Ord a ce No. 5 9. _y JOB ADDRESS D LOCATION.. ___- _ __ t_'___________ __ ____ _ Owner's Name------- ------ - -- --- - ------------ ----------------------=------------r------------------------------------------------- Phone-----`"r--------------- Address---------��_.-....&. -----------------'------ --- ---- --- --------- -----------------------------`---------------------------------------------------------------------------------------- ....... iContractor's Name---- ------- -------- - --------------------------------------------------------f•---------------•-------------•------------------ Phone---------------------------------- Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court Q Motel ❑ Other ❑ Number of living units: _-__ umber of bedrooms ___/___ Number of baths ___-_-_ Lot size _____ __ ----__��___-I�_- Ilo Wafer-Supply: Public system Community system ❑ Private ❑ Depth to Wafer Table -------- ft. Character of soil to a depth of 3 feet: Sand Gravel El Sandy Lo;/'No Clay Loam [3 Clay [-] Adobe Hardpan Previous Application Made: Yes ❑j No VNew Construct•:on: Yes Ela TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within460 fee��;t Yf Septic ank: Distance from nearest welf'4 ______Dista fr fo tion_' e ill___--___- _ _No, of comport,encs ----- Size y I --- --Liquid depth--- - -------------Capacity----�C19- Disposal' J�g Dis osal' field: Distance from nearest ell �E - _ Distance from foundation_ istance to nearest lot lin p /K ' 1--- �i } LL, Number of lines,___.______ _-_-_1 _ ___.-____ Length of each line___________ -� Width of french------ _ Type of filter mate �{�epth of filter material______r__ _______Totai length__________ __ ________________________'"� Seepage Pit: Distance fo nearest well----------------------Distance from foundation--------- to nearest lot line_.__:_--_________ ❑ Number of pits.1--------------------Lining material---------------------_-Size: Diameter---------------------- Depth--------------------------------- I Cesspool: Distance from nearest well-----------------Distance from foundation...................:Lining material--- ______________. I ❑ Size: Dlamoter-- ----------•------------------------;Depth------ ---------------------------------------------Liquid Capacity----------------------------gals. Privy: Distance from nearest well-------___________________________________________Distance from nearest b0ding_ ____- ______________---_______. ` ❑ - Distance to nearest lot lire------------------------------------------------•---------------------=--=----------------------------------------------------- ------------- kRe odeli apnyor�repairing d s r ----- - -------------------------------- ------------------------------------------•--------•-------••-------------------------•---- - -------..---- t - - - --- --- ------------------ - --s______--_.____-_._ ._-__ __--__-_-e___-_ ------------- ----- ------------------ --------------------------------------------------------------------------------------------------------------- -------------- I ------------ --- -------------- I .hereby certify that I have prepared this application and fha+ the work will be done in accordance with San Joaquin County ordinances, State laws, and rules and regulations of the San Joaquin Local Health District. (Signed) ,-�"7_.f_ - -------------------- -- - ------------------(Owner and/or Contractor) By:-------- ----------------------------I------------------------------------------------- ------------------------------------{Title)------------------------------------------------------------ (Plo+ plan, showing size of lot, Iota+ion of system in relation to wells, buildings, efc., can be placed ori reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY- DATE DATEI ---------------------------------------------------- BY---------------------- ---- ----------------------------. -------------------------- ----------- DATE --------------- = BUILDING PERMIT ISSttED – DATE 11 11— ---------------------------------------- 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--9-2M Revised W-2100