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APPLICATION FOR SANITATION PERMIT Permit No. ___ C-__ =_ _.41 (Complete 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 N JOB ADDRESS AND LOCATION------ ._f—�--_/-"---- ----�----- -- - - -- -�`-�'`-�---- -- -- ----s---------------------- •- ------- ----------- Owner's Name------------ ` %}� H-'--------- -1 r--- --- ---------------- Phone-mt,7 .. _ i ��-------- Address------------------------£ - ---- U,l - �_ I (p Contractor's Name-_�"`�-�- _Y y1 S� /i�--. '----- --•-------- Phon --- ------ Installation will serve: - Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ - II t D K Number of living units: _.�____ Number of bedrooms _Y Number of baths _1__--_ Lot size ----------------------------- -----------_---_.'_---_---- Water Supply: Public system o ,-Community system ❑ Private ❑ Depth to Water Table Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe J Hardpan ❑ Previous Application Made: Yes ❑ No $L New Construction: Yes ❑ NoX FHA/VA: Yes ❑ No� 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_-------_-----_------- ___.-----_-.----_---. -------- -- q S� ? Capacity ❑� f '�� No. of compartments Y Size = --------- Liquid de th p Number of lines_-. eil.�Distance from founda�o�_�________________Distance to nearest lot ll�e__ll�__..... Dis ..Field: Distance from nearest w Length of each line___________ ___ Width of trench.__tet---_---------------;-- _- ri" Type of filter mate cal- �+ Depth of filter material____!-------------Total length---.��__------------------------- Seepage Pit: ,,Dis•tance to nearest well_ _Distance from foundation___:_' ..Distance to nearest lot line__.-_--.---_ -Number of pi **ts-_� - ------- Lining 'Material--- Diameter-23.11p - x } S Cesspool: Distance from nearest well--------------- Distance from foundation--------------------Lining material--------------------.__---_-_-__--. �s ❑ Size: Diameter------------- --------------=---------Depth-------=--------------------------------------------LiquidaCapacity- -------------------_------gals. Privy: Distance from nearest well------- -----------------------------------------Distance from nearest building------------------- ❑ Distance to nearest lot line-------------------------- - ----- ------------------'------- ' ' ' e Remodeling and/or repairing (describe:____-_ _ -----: ------ - -- ---- - ---�--`---- ---------- ----------------------------------•--------------------------------•=•------ --------------------------------;----------•--------------------••-•----------------------------- ------ ------------------------------- -- --------------------- - t 4 } i ----------------------.._-_-_______-_---_-------__------_-__--------_--_----_____-_-----_--___-.---------_-_-__.__-----___-_-_-----__-_----_-_----.-------_--.--__----_--------_---_____--._____.-____--___._.__________-.._.__ 1-hereby certify-that I have prep�ar. d this application and that the work will be doneinaccordance with San Joaquin County , ordinances, State laws, and rules atfd r gulatans o , ha San Joaquin Local Health District. i ± t (Signed)------------------------------------- ---------------------- ---- -- - - ---- ---.------- ------------------- -.(Own(Owner fano r Contractor) By: r�. 1 Z-- . ------- - - - ------(Title)•- -- = 'r'x (Plot plan, showing size of lot, location a system in relation to wells, uildings, etc., can be placed on reverse side). FO ARTMENT USE ONLY APPLICATION ACCEPTED BY-- LCJh- ----------------------------- DATE---- REVIEWEDBY----------------------r------------------------ ----------------------------------------------------------------------------- DATE-------------------------------------- --------------------- BUILDINGPERMIT ISSUED------------------------------------------------------------------- ----------------------------------- DATE--------------------------------------------------------------- Alterationsand/or recommendations-------------------:=---------------------- ---------------------------------------------------------------------•......-----•-----,-----•----------•-•-------- ---------- - ------------------------ --------------------------------------------------------- -------------------------------------------•-----------------------•--------.------------------•--------------- FINAL INSPECTION BY: Date__.-. --- -- ------ -- ------------------------------'------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street I32 Sycamore Street 914 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California ES-9-2M . Revised 1.57 EP,CO.