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APPLICATION FOR SANITATION PERMIT Permit No. (Complete in Duplicate) Date Issued Application is hereby made to the San Joaquin Local Health District o9r a permit to construct and install the work herein described. This application.is made m compliance with County Ordinance ---------------------------- JOB ADDRESS AND. LOCATION-------------- - -- --------- ------------------ ----- Phone------------------------------------ Owner's ----------------------------------- Owner s Name----_---------- ----------- Address--------------------------------------- ------------------------------------------------------ Phone------------------------------- --- Contractor's Na --------------------- 'f--- -------------------------- - Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ __� Installation will sere Residence partment House ❑ / Number of li�ing units: j--- Number of bedrooms _ J--- Number of baths _____ Lot size . -_ ❑ �o'P�+h to Water Table _-____-- ft. / Water Supply: .Public system ❑ Community system Private ep j Grave4 Sand loam ❑ Clay Loam ❑ Clay ❑ Adobe ar par-❑ Character of soil to a' depth of 3 feet: Sand ❑ ❑ Y F us Application Mae: es ❑ No �Ew Construc+ion: Yes 5] + Preno pp dY TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) - Distance from u • ----------M rkal_____ 'Se tic Tank: Distance from nearest well__ - ------- v Li uid de th_______ _______ __________Capacity---- -- � ----------Size-_+ O&L No. of compartments_________ _ ..�- t ------ Disposal Field: Distance from nearest welL��Distance from foundation to nearest lot line-__:_ Number of lines.________ -_------ ---Length of each line----- 6 -*►- Width of trench____ .__�------------------------- gals. Type df filter material____-�'_ -.Depth of filter material:_-__�_�-�_�_______To+al length________ __a__________________________ 1"T-- Seepage Pit: Distance to nearest well___________________--Distance from foundation----- to nearest lot line--________-_____ Depth--------------------------------- _ ❑ Number of pits----------------------Lining material-.---------------------Size: Diameter----------------------- cesspool: Distance from nearest well "Distance from foundation------------------- Lining material_____---_______---___________--__---. Li uid Capacity gals. ❑ G P Y Size:.Diameter-------------------------- -----------Depth------------------------------------------------------------------------- Distance from nearest building----------------------------------------- Privy: Distance from nearest well------------------------------- ...: ❑ Distance to nearest lotine___________________ -- -------------------------------------------------------------- Remodeling and/or repairing (describe):__- - --------------------------------- ---------------------------------------- ------------- ---- -_-_ ---------- - --- -------------------- done 1 hereby certify have prepared this application the San Joaquin Local kHeal helmstr District. accordance with San Joaquuw oun y ordinances, -------------------------------------- --(Owner and/or Contractor Si nod ------ -----�-- --------- --------- -------- -�------ - _ ( � --- -------- ' - ---------- --(Title)--------- -------- --------- ------------ ---------------...-- By;t9Ffr (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 /fir 7 -r_ -------------------------- DATE------------- �---J--f- APPLICATION ACCEPTED BY___- --------------- DATE------------------------------------------------------------------------------------ REVIEWED BY------------------------ - BUILDING PERMIT ISSUED -- - ----------------------------------- -- ---------------- -------�------- - Alterations and/or recommendations:--------------------------- -------- -------- --•----•- ---------------- -------------- ------------ ------------------------------------------ �1 j -r/ - ------------ ----- - Date---- ------ ---�------ _ -'�-- --•--------------- FINAL INSPECTION BY----------------------- _ ------------------------ SAN --- - I SAN JOAQUIN LOCAL HEALTH DISTRICT 132 S camore Street 814 North "C" Street 130 South American Street 300 West Oak Street y � Tracy, California Stockton, California Lodi, California Manteca, California ES-9-21M 8-51 Revised W-2100