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APPLICATION FOR SANITATION PERMIT Permit No. `'__._, (Complete in Duplicate) "{ f Date Issued -_- Applica+ion 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. 5499. JOB ADDRESS AND LOCATION_ _._..° _2 4r -_____ `� _ T!4-,-•---_ ----------•---------•-----•-•-••-•••....--- Owner's Name..................... -----k---�.c-------�-�-=--�---5--�--�-2"�-- _ Address ------ Phone----------------------------------- Contractor's Name .........................................6-13.e- c-----------•------- Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: -------- Number of bedrooms -------- Number of baths -------- Lot size __________ ____________ ............... Water Supply: Public system Community system ❑ Private ❑ Depth to Water Table -------- ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe ET--Hardpan 0 Previous Application Made: Yes ❑ No ❑ 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.___.__..___.___.._._..-___... 171 No. of compartments--------------------------Size-------_------------ •--Liquid depth---------- ------------Capacity Disposal Field: Distance from nearest well-----------------Distance from foundation..___...__..._...._Distance to nearest lot line_---.____--_----- ❑ Number of lines-----------------------------------Length of each line---------- .._..___,.__.___._.Width of trench................. Type of filter material__----. ----_ . . ___ -_Depth of filter material-----------------------Total length.............____________•____:`-___'--s Seepa e Pit: Distance to nearest well.. Distance from foundation...t� D�tance to nearest lot ne._.S..... Number of pits.._._/ _ /r Lining material.__-Size: Diameter__"-K.4_.._.__De tn_____.. D P ' "--- - --------- Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material._.-_-..._____-_-_..__._. ❑ Size: Diameter----- ---------- -- ----•---•---:._Depth----------------- Privy: Distance from nearest well.............. ----------------------------Liquid Capacity -• - ._..- gals. ... ....__.---__- --------. Distance from nearest building-__-_.-_.____.____ ❑ Distance to nearest lot line__- ............. ....................•---------.... ------------------------------------------------------------ Remodelin and/or repairing (describe)_------------------ __ _____•-__- -- - ---moi - ------- ...•...... --- 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)f --- --- ------" -----------------------------------------------------(Owner and/or Contractor) By:. ------------------------------------------------------------------ ----•-•--•--•-------• --- ------...::..(Title). (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 . --- f DATE_REVIEWED BY_ --------------------- DATE. �7.�_. ........................... ---------- BUILDING PM --••---•----•---•----- Alterfat' --- -----]- --------------- ................................................ DATE.............................................................. rre afio n -------------------------------------------------------- -- ----------------------------------------•-------•--------------------------------•------ ------------ FINAL INSPECTION BY:. .. ._ -- ` ---------------------------------- Date.... --- ----------- ----------------- I SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 Wes+ Oak Street 132 Sycemora Street 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California ES-9-2M IA446'A71t/DOD 12-54