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APPLICATION FOR SANITATION PERMIT Permit No. (Complete in Duplicate) Date Issued 4 Applical•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 Ordinance No. 4` JOB ADDRESS AND L CAT N---------��--�------ --................ ------------------ --------------------------------------•-•-------------------... •------------ Owner's Nam f� - �.� Address ^"- ' ... - _.. Contractor's Name E' '= ----------- - Phone.-._ __�.� t - --- --- ----- -- --------------------- - -- --- Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ �I Number of baths - Lot size __�� -- - -/ ��-------------•- ------ Number of living units: __/'"--- Number of bedrooms /-- f --- Water Supply: Public system Community system ❑ Private ❑ Depth to Water Tableo- Character of soil to a depth of 3 feet: Sand E] Gravel [I Sandy Loam El Clay Loam ❑ Clay E] Adobes Hardpan ❑ Previous Application Made: Yes ❑ NoX New Construction: Yes No ❑ ��` TYPE OF INSTALLATION AND SPECIFICATIONS: ✓_ , (No septic tank or cesspool permitted if public sewer is available within 200•feet.) _ +Dlsposd�llli ptic nk: Distance from nearest well_________________Distance from foundation-------------------Material_:____-____.___--------------------------- No. of compartments--------------------------Size---------------•------------=---Liquid depth--- -----------------Capacity d: Distance from nearest well-----------------Distance from foundation--------------------Distance to nearest lot line----------------- Number of lines-----------------------------------Length of each line-----------------------------.Width of trench----------------------------------- Type of filter material-------------------------Depth of filter material-----------------------Total length--------------------.-_______________.____ ._ Distance fr m�foundation_-,Z�-- ---Distance to nearest lot line-_ Seepa it: Distance to nearest well _.__ __--.---_ _-___Liningm ---Size: Diameter----of pits__ De th I ----------------------- Cesspool: Distance from nearest well-----------------Distance from foundation-------------------Lining material______-_______ gals. ❑! Size: Diameter------------------------------ ------Depth----------------------------------------------------Liquid Capacity------------------------- g r -Distance from nearest building------------------------------------------- Distance -==------------------------ ------- --- ❑ Distance to nearest lot line----- � � ---- --- -•-------------------- ------------ _----- _ -`'j--- -------------- V_ 'R,mode, and/or repairing d ibe :------- =-Gv fU --- - -------- ------------------------------------------------------------ ----------•-------------------------------------------------- ! hereby certify t�iat I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State-Paws, and ufes nd regulations;of the San Joaquin Local Health District. .�/ _(Owner��n '6�Contractor ---- - /--- ---s' ----------- - "., (Signed) ----------------•------- By -- ------- ' (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be�laced on rave se side I FOR DEPARTMENT USE ONLY ---- - APPLICATION ACCEPTED BY�-------------- ---------------------------------------------------------------- ------ DATE��------ ------------------------------------------ REVIEWEDBY---------------------------- -��-- ---- ---------- ------------- ---------- ------------------------------•-------------DATE------- -------------------------------_x-----_---- BUILDING PERMIT ISSUED------------1� ----------------------------------•---------------------------- - iy .. !fir Alterations and/or recomme ations: --------- - ---------------------I------ - 0 ,� ----- '' �- , --- ---- --- �- _ ---- _-- - -----------••--------- '-- -::::::::: --- -- ------- -------------------------------------------- ---------- ---------------I---------- --- ---- -: --------------------------------------------- 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-2160