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APPLICATION FOR SANITATION PERMIT Permit F 1 (Complete in Duplicate) J/ 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 rdinance No. 5 JOB ADDRESS A (�Atil N--_ ----l- --- --------- - ------------- ---------- Owner'sName_ `. - ------------- Phone-----------.----------------- Address------to---/....-- ---i------ -------- ------ Contractor's Name---------- --------------------- - - ------------------------------------------------------------------------------ Phone----------------------------------- Installation will serve: Residence Apartment House ❑ rCommercial E] Trailer Court E] Motel ❑, Other E] 1 • Number of living units: __I Number of bedrooms _____l_ Number of baths __1__-_ Lot size _-_f----- ----------._.----------------- Water Supply: Public system. Community system ❑ Private ❑ Depth to Water Table -------- ft. Character of soil to a depth of 3 fee+: Sand Gravel Sandy Loam Clay Loam E] Clay E] Adobe�ardpan ❑ Previous Application Made: Yes E] No 2 ❑New Construction: Yes E<No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if publip sewer i available within 200 feet ) e Septic ank: Distance from�nea�est we11 � '�"LTisfa��jce fro ffqu tion_�_�___________3.MMat r No. of compartments--------- ------- ---Size?. ____ __Liquid ciepth--- - _ - Dispos Field: Distance from nearest wel� istance from foundation✓ �is#ante to nearest t i r J - Number of lines_________ ______!__.______-__ __Length of each line___________ a- _rt._-Width of trench. ------ ___:..___...________ \ Type of filter materi _ __ _i kepth of filter material____._:_/________Total length�_______ _ ________________________ O Seepage Pit: Distance to nearest well______________________Distance from foundation-------------------.Distance to nearest lot line----------------- F1Number of pits----------------------Lining material-----------------------Size: Diameter----------.------------Depth---------------------------------- Cesspool: Dl stance from 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----------------------- -------------------------•--------------------------------------------------------------------------------------------- Remq�elin and/or repa { cr' =-------------------------------------------------•------------------------------------------------------------------•--------------- ------- __ f[ ...... ..............J. - -----------!------------------------------------------ ----- : •-- --------------------------------------------------------------------------------------------•.---------------------------......-------- I hereby certify that l;have prepared this application and that +he work will be done in accordance with San Joaquin County ordinances, State laws -,, acrd rules and r gu ations`offtthe San Joaquin Local Health District. (Signed) /Y" ----------------------------------------------------(Owner and/or Contractor) By:----------------------------------------------- --------------------------------:----- --------(Title)------------------------------------------------ I ---------- --------------------------- --------------- (Plot plan, showing size of lot, location of system in relation to wells, biuildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY. APPLICATION ACCEPTED BY- --------------------------------------------------------------------------•---•--•--------- DATE-----------•------ ---------•-------------------- -- REVIEWEDBY---------------------------------- ---- - -------------------------------------------------------------------------------- DATE-----�-----------_------------••--------------------- BUILDING PERMIT ISSUED ---------------------------------------'- ----------------------- DATE. ; Alterations and/or recommendations------------- -------------------------------------------=----------------------------------------------------•------------------------------------------------ -------------------------------------------------------------•----------- ----------- -----------------------------------------------------------------------------------------•-•------------------------------------------- ------------------------------------- ------------- ----------------------------------------------------------------------- ---------- -•----- ---------- --------- ------------------------------------------------------- FINAL INSPECTION BY:-- '_0_AA-- a------------ Date------------- -----------------•------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 Wes+ Oafs Street 132 Sycamore Street 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California ES-9-2M 10-52 Revised W-2100