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r � , f7 APPLICATION FOR SANITATION PERMIT Permit No. . (Complete in Duplicate) Date Issued Application is hereby made to the San Joaquin Local Health District-for a permit to constru a install the work herein described. This application is made in compliance wit ount Ordinan No. 54 . ' JOB ADDRESS AND'LOCATI N.._-- ------ ............ A4Owner's Name = a Phone------------ --------------- ------i Address------------------ = - ------- ------ CJ� Contractors Name--.-----= ' .. = r - --- hone_.:. : Q _ !d Installation will serve: ,Residence ❑ Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel Cl Other Number of living units: -__.____ Number of"bedrooms ----_--- Number of the ,��Lot size __='r___.---_-F------------- Water Supply: Public system❑ Communifiy system ❑ Private epth to Water Table?_ tt. t: Sand Gravel Sand Loam ay Loam ❑ Clay ❑ Adobe Hardpan ❑ - Character of soil to a depth of 3 fee � ❑ Y Previous Application Made: Yes ❑ 'No New Construction: Yes No ❑ s - TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tank:a Distance from nearest well---------- _.---_Distance from foundation--------------------Material------------------._-_-_-._ ----_------._----------. No. of compartments R I.. Size---------------------------------Liquid depfh--------------- ---------Capacity-------------------- a� r Disposal F• d�Distance from nearest well-_ _ _`--- Distance from foundation__ ---.Distance to nearest Number of lines_( ^- :�--- Length of,each line__ Width of trench._ a__'°�"`------ Type of filter material~ ---- -�Depth of filter materia!-- - -- -- --------Total length -- ------------------ ---------- ... e Seepage Pit: Distance to neares weli__ _Q ____._._Distance f m.fo dation___.o---_-___--.Distae to nearest lot -- Numf�er of pits._p` tA- -------Lining material- _ !-Size: iometer--.----3......-....Dept h---.---�---�. Cesspool: Distance from nearest well_______________ Distance from foundation-------------------.Lining material--------------.------------------__.- Size: Diameter -r --------- ---- - =--Depth --------- --- ------ ---: Li_quid Capacity------------------- Privy: -- als. ❑ ' st ._ ° -- buil--ing*-----'--- ---------------------- --- Priv❑ � Distance to eareDistance from stelot-line l _____________ ___________ Distance from nearest bui{din � Remodeling and/or repairing (describe):----_---'._---- ------ = -� - _ NZ i - � f ------------- -•- ---- - ----- -- - ---- - ------------ f y---------- _ _-4----- •---------p---pi--------••-- ---pp------•----------Jaa ui^-- ---------------------------------------------------'alth Distric•- --.------------------q-:-----'---------- �°M __ yI khereb certifythat I have prepare this application and tha+ the work will be done in accorda a wifh San Joaquin County ordinances, State laws, an rules and [at* ns oft S n w . r and/or `ntractor Ss ne - -- -- ------------ ) Plot la^, showin size of lot, location . --anTitle).___ .. _ __ _ _ l t �•-------• ------ --------------------------'---------------------- -wing --------------- I ( plan. - g n of system in relation +o wells, buildings, etc., can be placed on reverse side]. 1=0R DEPARTMENT USE ONLY i, F APPLICATION ACCEPTED BY-------- DATE.. = { ---- -- ----- =-------------------------------------------------- ._ REVIEWED BY----------------- -- - DATE BUILDINGPERMIT ISSUED--------------------------------•---------- ----------------------------------------------------- DATE------------------------------------------------------------- Alterations and/or recommendations---------------=--------------------------- - ----------------------------------------------------------------•-------------••------------- . . 1 ----•-•------------•----------------- F --------------------------------------...---------------------------------------------------------------------------------•--------------------- ------------------------------ ---------------------------------------------------------------------------------------------------------------------------------------------------------- I ---------------------------------------------------------------------•------------------------•----------------- . I Date.--- FINAL INSPECTION BY:-_ _---._ --- ---------- ;SAN JOAQUIN LOCAL HEALTH DISTRICT 1 130 South American Street 300 West Oak Street 132 Sycamore Sfreef 814 Worth "C" Street Stockton, California Lodi, California Manteca, California Tracy, California aa ES-9-2M 10-52 Revised W-2100 r