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APPLICATION FOR SANITATION PERMIT Permit No. :_- .�_- 03�`2 lComplefe 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. 5 JOB ADDRESS ND LOCATION.. �. S r ---------------- wner s ams_---------e-------- P = ------- ----- --------------------------- --------- ---------- ----------------------- ------------------------------------------- - Phone------------------ Address-------------er � X- -- ontractor's'Name-------------- ---------- Phone. Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court l ❑ Motel ❑ Other ❑ Number of living units: ___!--_ umber of bedrooms -,� Number of baths ----4- Lot size Wafer Supply: Public system Community system ❑ Private ❑ Depth to Water Table -------- ft. Character of soil to a depth of 3 feet:, Sand ❑ Gravel ❑ Sandy Loam I❑ Clay Loam ❑ Clay ❑ Adobe [ ardpan ElPrevious Application Made: Yes E] No LK New Construction: Yes-VNO ❑ FHA/VA: Yes ❑ No P_0*� TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or'cesspool permitted if public sewer is available within 200 feet.) Septic Tank- Distance from nearest well----------------- Distance from foundation--------------------Material---------------------------------- - -------- -. . ❑ No. of compartments--------------------------Size---------------•---------------.Liquid depth--------------------------Capacity Disposal Field: Distance from nearest well------ .___--__Distance from foundation---_----_!.--_----- Distance to nearest lot line----------------- ❑ Number of lines---------------------------------- Lengfh of each line----------- --------, -------.Width of french Type of filter material-------------------------Depth of filter material--------------- ------Total length--------------------.-------------- eepag rt: Distance to nearest well-n/ "p-------Distance fr m fo ndation--_ �tIr ' Number of pits__-.-___- _ L bt%ice to nearest lot line_S-_._---5 Lining material----_; .-_Size: Diameter--- Depth --- I Cesspool- 'Distance from nearest well-----------------Distance from foundation_-- _-.--=---_Lining material--------- -----__ -------------------- ❑ Size; Diameter Dept h -------=---------------Liquid Capacity----------------- gals. Privy: Distance from nearest well____ --___-- Distance from nearest El Distance to nearest lot building --- line------------------------------ ------------------- --------------------------------------------------- ------------------ 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 and regulations of the San Joaquin Local Health District. (Signed)---------- ----------- ------------••--- -----------------------------------------------------------------------------------------------------------------------(Owner and/or Contractor) By:---------------------------- Tale (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 APPLICATION ACCEPTED BY------------------------------- -•----- -- DATE REVIEWED BY------- -------------- ---------------------- -- I------ DATE -- -- ----------------- --------------- BUILDING PERMIT ISSUED------------------ ---------------------------- --------------------------E--- DATE Alterations and/or recommendations:--__-'- - y --------------------- — ----- l1-� - -- - ---•---------------------- - ------------ ------- -- l - �° ----------------------------------------------------- �o" FINAL INSPECTION BY:---_-- --- -- ------- Date------- --- - - - mss_------ - � -_--�-�-... -------- --------------. 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-4-2M Revisea 1-57 F.P,CO.