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• Permit No. # \l ' APPLICATION FOR SANITATION PERMIT � . — (Complete in Duplicate) Date Issued _ -/-"- Application is hereby made to the San Joaquin Local Health District forp permit t construct and install the work herein described. This application is made in compliance with County Ordinance No. 5 JOB ADDRESS AND -- -- ' r - --- --- ----- ----- ----- - - --------- ------------- Phone------------------------•-------••-- Owner's Name Address----------- f 4g ':�`-•-- 1_ _ -------•- ------------------------------------------------------ ----------------------------------- Contractor's Name -- Phone - -- ---------------------------------------------- Installation will serve: Residence ❑ Apartment House ❑ Commercial Trailer Court ❑ Motel ❑ Other ❑ fLot size -� - ----------�--------------------- Private of living units: -1—Number of bedrooms . ____ Number of baths __ "" Water Supply: Public system Community system ❑ Private ❑ Depth to Water Table _$V ft. Character of soil to a depth of 3 feet: Sand E] Gravel F] Sandy Loam El Clay Loam ❑ Clay E] Adobe Hardpan ❑ Previous Application Made: Yes ❑ No 5t?0" New Construction: Yes ❑ No �FHA/VA: Yes ❑ No TYPE,OF INSTALLATION AND SPECIFICATIONS: (No septic tank or'cesspool permitted if public sewer is available within 200 feet.) f eptic ank: Distance from nearest well-________________Distance from foundation_____.____________.Material_________--___.__.___._ ____________------------ id depth_____________ _-------- Capacity No. of compartments___._.___ ._ Size _ Liqu �. ispos seld: Distance from nearest well------------------Distance from foundation--------------------Distance to nearest lot line---------------_ � a ---------Length of each line------------------------------of lines____________________---_ ---------- Width of trench----------------------------------- Type of filter material-------------------------Depth of filter material--------r�-------e-----Total length---------------------------------------f - aSl, e Pit: Distance to nearest well_ `Distance f m f dation_�r,?!E_._______.Dist ce to nearest lot line_Sze: Diameter____ De th___---Linin material--- ---- P44' ---------- Number of pits.-_--/_____-- - g Col: Distance from nearest well-----------------Distance from foundation-----______________Lining material___.___________----- ---""-"-als. Size: Diameter-------------------------------------Depth---------------------•------------------------- ---Liquid Capacity----------------------------g ------------------ -----------------------Distance from nearest building------------------------------------------ 1 Privy; Distance from nearest well_____. - ❑ Distance to nearest lot line----------------------- -------------------------------------------------------------- .... k , 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 ruj# and regul ions of he San Joaquin ,Local Health District. {Signed_ .,r - r----------- Contractor) ------ ---- ------ ---(Title)---------- - ---- -------- -------------------- (Plot plan, showing size of lot, ton of system in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY ------ DATE -------------- - - DATE REVIEWED BY------ BUILDING PMIT ISSUED------••---------------- - DATE --- -- Alterations an /or recommendations:_____ ----- ---------- ----r------------------------------------------- ----------------- ' �-=" Y y, FINAL INSPECTION BY----- --- ---------- --------- ---- --- ------------- Date------ ( ----------------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 3oo Wes+ Oak Street 132 Sycamore Street 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California ES-9-2M . Revised 1.57 F.Pko