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FOR OFFICE USE: -------------------------------------------------------- APPLICATION FOR SANITATION PERMIT Permit No. --------------------------------------------------------- (Complete in Duplicate) �J E/ This Permit Expires i Year From Date Issued 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. 5 JOB ADDRESS AN CATIO + -------L�� - '---------------------------------------------------------------------------------------- Owner's ------------------ ••----Owner's Name---- ----------------- - ------ Phone------------------------------------ Address............ ----------------------- -Address____________ _ _ _ ` --------------------------------------------------------------=-................................ Contractor's Name-------------------- -------------------------------------------I............................. ...-. Phone..__.......------------------_-- Installation will serve: Residence 'Apartment House ❑ Commercial ❑ Trailer Cpur<t'=❑ Motel ❑ Other ❑ Number of living units: _ ---- Number of bedroomsy_-_ Number of bath s/1 C*'-Loflsize,�:A;5 I-F` _F Water Supply: Public system ❑ Community system ggo'lrivate ❑ Depth to Water Table (t. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe ardpan ❑ Previous Application Made: (If yes,date--------------------) No R__,�New Construction: Yes 2-"'No ❑ FHA/VA: Yes ®—'No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.1 Ar _ Septic Tank: Distance from nearest well_----`" -_Distance f om foundation. .-T------------.Mate jai---- - -- --- !---. No. of compartments-.-�----------------Size- Li uid de th_ y -.-_-.Capacity - Disposal Field: Distance from nearest ell------------------Distance from foundation._e.-_ -_ Distance to nearest lot line---.-�---. Number of lines___--- - - Length of each Iine�-� 7- i.Width of trench___��/____---------------------- Type of filter material / -Depth of filter matenal-- ` ------_Total length-.-,� �------------------------- Seepag Pit: Distance to nearest well----------------------Distance�m foundation_fe_....- Distance to - nearest lot iine�_�---_ Number of pits---- ------------Lining material__-- t _Size: Diameter-- - --- Depth--- -- k Cesspool: Distance ff•om nearest well-----------------Distance from foundation....----------------Lining material------------__--------_------_-------. ❑ Size: Diameter-------------------------------------Depth----------------------------------------------------Liquid Capacity----------------------------gals. Privy: Distance from nearest well-------------------------------------------------Distance from nearest building------------------------------------------ ❑ .. Distance to nearest lot line------------------------------------------- --------------------•-••--••-• ---------------------------- ----- ---- --- - Remodeling and/or repairing (describe) - -••----- ------•--•----------------------------------------- ------------------------------------------ ----------------------------------------------------------------------------- --• ----• ------•-••--------------------------------------------------------------------------- 1 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 and egulations of t e San Joaquin Local Health District. (Signed)-------------------------------- - -- - ----- - ------ -- ----------------- --------------------------------------------- w�or Contractor) �J - (Piot plan, showing size of lot, location of system i ation to wells, buildings, etc., can be paced on reverse side). FOR DEPARTMENT USE ONLY APPLICATIONACCEPTED BY------•----- ------ --•- ------- ---------------------------------------------------...--- DATE----------------------------------------------- REVIEWED BY---------------------------------------------- -------------------- ---------------------- DATE-------------------- BUILDING PERMIT ISSUED-------------- ---- ------- -------------------------------------------- ------------------- DATE----------------------------- - - ---------------------------- Alterations and/or recommendations:-----="-- --------------- --------------------------•-•-------------•- •----------------------• --- •-------------•--------:------•------------------------ ----------:------------------------------------------------- - -- -----•- - ----- ------- -- ---- -------- - -- - ----- ------------------------------------------------------------------------------------------------ /J J Date-----------/ - FINAL INSPECT B ------ ----- -------- ---- --- y SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,California ti- x Monteca,California Tracy,California ES-9 PlEv16ED 6.59 F.P.cG,zM 6.6o v '