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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 for a permit to construct and install the work herein described. , This application is made in compliance with County Ordinance No. X99,. i ---------------------------------------------------------- -- JOS ADDRESS AND TI� J `----- --- --- = `- Name----- -- ---------- '-- --- ----- ----------------------------------------- Owner's; Ph one------------------------------------ 11 r - ------------------------ Address l .t �'�- --'��--- ------------------------------------------------------------------ - Contractor's Name------------------------------ Phone Installation will serve: Residence A artment I-iouse,, Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ i Number of living units: _- -- Number of bedrooms _ ._ Number of baths--_ y_`Lo`t size -- - ----------------- - Private-F] Depth to Water Table _ ft.Water Supply: Public system Community system .•- , Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ 'Clay Loam [❑ Clay ❑ Adobe-Ef Hardpan ❑ Previous Application Made: Yes E] No ® New Constructidn: Yes �Nor(]�04/VA: Yes ❑ No t❑�' �:�, TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or'cesspool permitted if public sewer is available within 200 feet.),f ti Septic Tank: Distance from nearest well____--- ------Distance from foundation_--/�,__.__--Material-__- - ------=------- No. of compartments------ -- ------------ 'Size_ -/ - - _---Liquid depth---�. f-- --------Capacity--- ,Q -_-- Disposal 1=' Id: Distance from nearest well______ ______Distance from foundation--; -f:`.D,'sstance to nearest lot line---��- Number of lines_________ ___ __ ____Y Length of each line___.--_ `'- ---`.Width of trench.__ r_ __ ' r f g ' t f Depth of filter material---- --length___._- _____________________�__. Type of filter material__ �.��---- 3 .r \` Seepage P' : Distance to nearest we€I-----:'.7"-------- Distance fr m f ndation _- -.:'_ Distance to nearest lot line__-________ [V� i Number of pits-------- ----------Lining matiai__ ---Size: Diameter--,,,, V�-.__-Depth---- -- ---'----------- �V Cesspool: Distance from nearest well-----------------Distance from foundation-------------------.Lining materia4----------------------------------- __. V ❑ Size: Diameter--------------------=- =--==r -De"Depth`_--------------------------------------------------Liquid Capacity-------------=-------------gas . –. Privy: Distance from nearest well-________________________________________________Distance from nearest building_____________.___------_______.______.- ❑ Distance to nearest lot Iine------------------------ --- ---- --------- ---------------------------------------------------------------------------------------- N ----------------------------------- Remodeling and/or repairing (describe):------------------ = ------------------- ---------------------------------------------------- ----- ------ - --•------ -- � � _ `�---- -----------------•--------=-------------------- ---------- ------- -------------------------------------------- -- -------- - - --------- -------------- 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 rules aAd regulations the San Joaquin Local Health District. ----------------------j� Contractor) (Signed)--- r ----, ---- ---------------- ---------'.----(Title)---- (Plot plan, showing size of lot, locati of system in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATIONACCEPTED BY-------------------------------- - --------------------------------- -------. DATE------------------------------------------------------ REVIEWEDBY----------------------------•---------------- •---- -------------------------------------------------------- DATE-------------------------------------------- BUILDING PERMIT ISSUED----------------------- '- DATE ----J.- Alterations --------------- and/or recommendations:__._ -------------- -----------------------•---------------------------•------ _ --------•-- ------------ �f (- -- -------------- ---------- FINAL INSPECTION BY:-------------- ----- --- --- -------- ----- Date---�71_ �--.---------- - ---------------------------- SAN JOAQUIN�L AL- HEALTH .DISTRICT 130 South American Street 300 West Oak Street- 132 Sycamore Stieet�,-, 814 North "C" Street 111. x Stockton, California Lodi, California Manteca, California Tracy, California SES-4---2M Revised 1.57 F.P.CO.