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APPLICATION FOR SANITATION PERMIT Permit No. .__... ..�... �,........ /_.... (Complete in Duplicate) Date Issued jpplication is hereby made'tooth a San Joaquin Local Health District for a permit to construct and install the work herein described. This application is made in compliance with Count,(,-Ordinance No. 5 JOB ADDRESS AND LOCATION ---- ---- - ------ �- ,Owner's Na G - Phone- Addre --- --- ---------------- ---------------- Contractor's Name--------- - - -- ---------------------------•--------------------------------------------------------------------- Phon 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 Hardpan F1Previous Application Made: Yes E] No [� New Construction: Yes; No� FHA/VA: Yes ❑ N� \ TYPE OF INSTALLATION AND SPECIFICATIONS: ' (No septic tank or'cesspool permitted if public'sewer is available within 200 feet.) Ary ptic Tk: Distance from nearest well-__-_---____---_Distance from foundation---.-_-_--_-______-Material---------------_--------------------------------- No. of compartments-------------------------Size-----------------------•-•----Liquid depth---------- --------------Capacity--------------_--_---- isposal Id: 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 materia----------------- ____ otal length_____________________________________--- See a e it: Distance to nearest well-__Distance from f clatio -__--•- Distance to nearest lot li Number of its_-.- / Linin materia ,..Size: Di meter.__ _ P / 93 Depth of ---- ------- ------ Cesspool: Distance from nearest well-----------------Distance from foundation.-------------------Lining material________-.-_--___.______._________. ❑ Size: Diameter-------------------------,- ------Depth----------------------------------------------------Liquid Capacity-.--------------------------gals. Privy: Distance from nearest well------------------------------------------------- from nearest building.__-_____-__-__-__-_____________----_-_. ❑ Distance to nearest lot line---------------------^-- --------------------G-�---------- Remod lin nd or repairing describe):_.__ - -- --------- -- -- ----- ----- -- --- • -- ------- --------••- --------------------------••-----------------------•---- ------ ------------------------ --------- --------------- ------------------------------------------------------------- ----------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------- I hereby certify that I have prepared this application and that the wgrilwill be done in accordance with San Joaquin County ordinances, a la s rules a re I tions of t San Jo in Lo Health District. A (Signed)._ _. �- /._ _ ________________ _______(Owner an Contractor) ------- ------ ------------- ------------- gY� = - --- -------------------------------------------- ------------------------------- ---------(Title - - -- - ---------- -- ---------------- (Plot plan, sh ng size of lot, location of system in relation to wells, buildings, etc., can be pl ed on rave se si�. FOR DEPARTMENT USE ONLY APPLICATIONACCEPTED BY------------------------------------------------------------------------------------------------- DATE------------------ - - REVIEWEDB.Y------------------------------------ ------ ------ ------- ------------------------------------------ DATE----------------- BUILDING PERMIT ISSUED-------------------------- --------------------------------------------- DATE. - Alterations and/or recommendations:--------- ---------------------------------------------------------.................. ------------- ----------•---------- --- - - ---- --------- ----- ! � - - ---- ---------- -- ------- - ---- --------- ----- ----- -- ------------------ FINAL INSPECTION BY l Datev 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 1.57 F.P.CO. t'