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FOR OFF CE USE: - ------ -- 3_- - APPLICATION FOR SANITATION PERMIT Permit No. .._1-�--�.�- t..'` `- - . --------- --------------- (Complete in Duplicate) ��! __..___________________ - _ _ -_ _._-_________.___ This Permit Expires 1 Year From Date Issued 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 co lance w Oran N . 4 . JOBADDRESS AND LOCATION...--- ----------------------= --------------------------------------------------•----•--------------------------- Owner's Name =� -� . Phone v ( ' ............. ...-...Address--------------------- ............ .. . --=--•-••-•---- Contractor's Name............ ------------------------•-----------------....--------•- •----------------- Phone.................................-- Installation will serve: Residence g3l'^Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: ... Number of bedrooms _,Z. Number of baths ._1... Lot size •--••_-- Water Supply: Public system [ff'-Community system ❑ Private F1 Depth to Water Table •� 4_ ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe Hardpan ❑ Previous Application Made: (If yes,date-_.----_- ---------) No 93"'—New Construction: Yes ❑ No 8'FHA/VA: Yes �o ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if pub&sewer is available within 200 feet.) Septic T nk: Distance from nearest wel --• ----Distance from foundation.J47...........Mat�ipl _G No. of compartments_--__ ___----_-.._-_Size. ._ -. __ �-__ Liquid depth__-!_,pe..._________CapacitY.... .___.._ Disposal Field: Distance from nearest well--- from foundati ___l ._�_.._.Distance to nearest lotline._J.�_..... Number of lines-------!__---------- ___�_..�__�_ -ength of each line------_�_ .__'_. Width of trent vd�........................... Type of filter material.../_, ,, _IX/%Depth of filter material____f` _r_`____Total length ------_-_•---_-•_______________ s , L Seepage Pit: Distance to nearest well---- ___--Distance f m f�oJ°ndation.... _/.-_Distance to nearest lot line..._ ..._.. C Number of pits.......L------------Lining material--_��_ ,?!' /-..Size: Diameter-JI?............Depth.-.,O;-- Cesspool: epth.-..v •Cesspool: Distance from nearest well-----------------Distance from foundation-_.-_-_--__.._---__.Lining material..................................... ❑ Size: Diameter------ -------------------------------Depth---------••--------------------------- -------------Liquid Capacity............................gals. Privy: Distance from nearest well-------------------------------.-----------------Distance from nearest building--------._-__-______--____•----_______-_. ❑ Distance to nearest lot line--------- -----•-----------------------------------•---------------------------....................................------•• --------------- 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 rules and relulations of the San Joaquin Local Health District. �.�(Signed) -'�- �•��'----•-- - ""�'�=` -- -------------------- •--,y=----------------------------------•-------- vMher�a er Contractor) B = ------------------(rile)-----c�Z 7,67 ............ --------- (Plot plan, showing size of lot, location of system in re ' n to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY...........=- '- _'cam-- -- -------------------------------------------- DATE------. Ja- --� ----------------------------- REVIEWEDBY----------------------------------------------_ ---- ----------------------------------------------------------- DATE------------------------------------------------------------ BUILDINGPERMIT ISSUED---------------------------------------------------------------------------------------------------- DATE------------------------------------------------------------- Alterationsand/or recommendations--------------------------------------------- --------------------------------------------------------------------------------------------------_---_------ ------- -------------------------- -------- --------------------- -- - :- --�r `-- � !l °--• .......-•---- ------------ _-------------------------------------------------------••• .....-- ---- --•------ / ------------- FINAL INSPECTION BY------ -- ---- -- --- -- Date.... J--3j` SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,California Manteca,California Tracy,California EB-9 REVISED B•59 F.P.CO.1M 6.60