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{ yvv APPLICATION FOR SANITATION PERMIT Permit No.L (Complete in Duplicate) Date Issued ,plication 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 incompliance with County Ordinance No JOB ADDRESS AND LOCATION..___- __ _/_____-__ - .a..:....`._ ------ ----------------------------------------------------------------------- - ---ph_ 4111_V------ .---- Owner's Name - - - = Phone --------------------------- Address--------•-•- --- - -------------- -----------------------------------------------------------•------------------------ -----------------7--- ---- Contractor's --- ------------------------ Contractor's Name l - _lt------------------------------------------------ Phone__ . Installation will serve: ResidenceApartment House ❑ Commercial ❑ Trailer Court E] Motel ❑ Other ❑ Number of living units: _-__- Number of bedrooms _J/' Number of baths __ ___ Lot size __Lp O L. --------------------- Water Supply: Public system'f4 Community system ❑ Private ❑ Depth to Water Table _,�.o ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe K Hardpan ❑ { Previous Application Made: Yes ❑ No 9- New Construction: 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-___.______________._.------_____..____________- ❑ No. of compartments------------- ------------Size--------------------------------Liquid depth--------------------------Capacity------------------ i Disposal Field: Distance from nearest weil__(yB( , -.Distance from foundation__ .._"__.Distance-to nearest lot line-------e-------- Number of lines___ __..___Length of each line___ ?Q_-`_ _ Width of trench..�f.t I! r t -------- Type of filter material/ /,.- _Q&6epth of filter material---__/�-_.________Total length------------ �� ----------- Seepage Pit: Distance to nearest well-----_----------------Distance from foundation--------------------Distance 10 nearest lot line.______.____..._ ❑ Number of pits----------------------Lining material------------------------- Size: Diameter.......__.__..._....--Depth------.--------_----------------- Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material__.._____..___.__--_-----___.______- ❑ Size: Diameter----= ----------------------- ------Depth----------------------------------------------------Liquid Capacity---------------------------gals. Privy: Distance from nearest well---._____._______________________._.________--Distance from nearesr building_____-_______-----------_______.____-_._. v ❑ Distance to nearest lot line------- -------------------------------------- •------------------ ------- Remodeling -----Remodeling and/or repairing (describe):---- = r - -------- --•-••------•---------------------- •--------------------------------- --•-•---------- ----------------------------------------------------------•------•-----------------------------------------------•••--------------------•------ ------------------------------- -- I --------------------------------------------------- ----•----•------------------------------------ -------------••----------------------------------------------------------------------- ------------------------- I hereby certify thaf� e prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State law and ru s and regulations of the San Joaquin Local Health District. { (Signed} 7 - (:S_ ,o� 1_ ___ " --------------- , (Owner and/or Contractor) BY� ------- = j� s_ {Title)------ ---- ._ <•,r�' " (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). a FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY---------------------------- - -- ------ DATE-- ---•-• -;_•f-- -f•-- REVIEWEDBY-------------------------------------------------------- -------------------------------------- -------- DATE BUILDING PERMIT ISSUED-------------------------------------------- --------------------------------------------------------- DATE Alterations and/or recommendations---------------- ------ --------------------------------------------------•--------------------•------------------------------ ----------I---------------------------•----------------------• -- ••---------- --------------------------------------------- FINAL ---------FINAL INSPECTION BY:----- ....... ----------- ----------------------------- Date--------- �' 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 10.52 Revised W-2100