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w' APPLICATION FOR SANITATION PERMIT Permit No. $' (Complete in Duplicate) Date issued 1 ppliceion 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 IN 5 JOB ADDRESS AND OCA ON - -- ---- { Owner's Name ------------------------------------ ----------------------------------- -------- Phone----•----•-------------------------- Address----- Contractor s Name-_____-. . Phone.._,.?__1�__��c Installation will serve: Residence,° Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: __;/___ Number of bedrooms . � _ Number of baths _/___ Lot size -----_t5", '_/ ----------------------- Water Supply: Public system ❑ Community system ❑ PrivateX Depth to Wafer Table_ ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adob Hardpan ❑ Previous Application Made: Yes ❑ N x New Construction: Yes No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) ptic Ta k: Distance from nearest well_________________Distance from foundation--------------------Material_____----.---.______________________.._---______. ` No. of compartments------------- ------------Size-------------------------------Liquid depth--------------------------Capacity isposal Fiel Distance from nearest well-----------------Distance from foundation--------------------Distance to nearest lot line____________-___- , Number of lines-----------------------------------Length of each line------------------------------Width of french.--------------_-------------___ -- r Type of filter material__--- Depth of filter material-----------------------Total length----------------.------------------------- Seepage -____.___________--__._ See a e Pit: Distance to nearest well p g _:,.4 ____Distance f om fo'ndation--/V__�......Distance to nearest lot line -5--. Number of pits___1_________ -Lining material -__-Size: Diameter____,_7!-------------Depth_ Cesspool: Distance from. nearest well-----------------Distance from found ation------------------;.Lining material------------------_-.______.___-___.-. ❑ Size: Diameter--------------------------------------Depth-------------- -• ••-------------------------------Liquid Capacity----------------------------gals, p ' Privy: Distance from nearest well------------------------------------------------ from nearest building.___________-_____________-------------_. N ❑ Distance to nearest lot line----------------------------- ------•-------•------------------------------------------------------------------------------- Remo lin and/or re air describe :___ 9 / p g A, -71 •...---------------------- -- ----•-------------------------•--------------------------------•------------- -------------- ---------- -- ------- ------------------------------- ----------------------------------------------------------- -------------------------------•----------------------------------------...--------------------------------- 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 r les an ire ulations of the San Joaquin Local Health District. -- ---------•----------------------------------------------------------------------------------- (Owner and/or Contractor) (Signed)------- �' �2'•. f BY:......-------------�', _ (Ti+le) �� {----------------- (Plot plan, showing size of lot, location of system in relation fo wells, buildings, etc., can be p aced on reverse sid FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY- ------------------------------------------------- ---------------------------------------- DATE.- REVIEWED BY--------------------------------- DATE. BUILDING 'PERMIT I.SSUED---------------------------- ------------------------------- -- -------------- DATE --- - Alterafions?and/oi rscommyendatiopsx-------------------- --------------------•--------------------•-y,=....------.a----- •-----...-•---------- ------------------- �� - -- ---- �-- - 4 -- �-- t-- ---------------------'n--•---- ----- - --- -------- �-.. -� --- --------------------------- --------- ---------'k---------------•--•--------------------- ------------------------------------------------------- ------------------------------------------ •-•--------------- FINAL INSPECTION BY------------------ ---•-- ------------------------------- Date------ --7------------------------ ------------------------` 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-2100