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APPLICATION FOR SANITATION PERMIT Permit No. - � (Complete in Duplicate) Date Issued Application is hereby made to the San Joaquin Local Health District for a permit to construct and install ribed. This application is made in compliance with Coun� O anc1? ,0-449. � � © JOB ADDRESS ND CATI ' . Owners Name ---------------------------------------- ----- Phone d4 ...... Address-------1__ � ------- ------------------------------------•---- rl Contractor's Name--- --'_ - ----i- ------- --------------------------------- f---- == '-- ------------------ Phone.-.-.--------------------------- Installation will serve: Residence Apartment House ❑ Commercial ❑ Trifler Court ❑ Mot I ❑ Other ❑ Number of living units: ---i--- Number of bedrooms --- --- Number baths _1... Lot size _ Water Supply: Public system 0 Community system J-1 Private Number to Water Table _____-__ ft. Character of soil to a depth of 3 feet: Sand Gravel ❑ Sandy Loam Clay Loam [I Clay F] Adobe 2/Hardpan ❑ Previous Application Made: Yes ❑ No New Construction: Yes No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if pdbl'c sewe is available within 200 feet-1r - --- ---1----- --- .-„--,-'-�istancq from punc�tpn----�- --__!�IVlate i�l----------------Septic ank: Distance from nearest wel '_Q�""D' No. of compartments_________ Size__-_.x_ X ._Liquid de�th________ ___________Capacity__!___ Dispos Field: Distance from nearest well_rr _Q_�___Distance from foundatien..4_N_-------Distance to nearest lot lin Number of lines__________ _____1__----------- ength of each line__________. E_S, ____ _.Width of trench________._ 4c� Type of filter materi p g _�___ __ ___ th of filter material_________�__g____-_Total length Seepage Pit: Distance to nearest well----------------------Distance from foundation--------------------Distance to nearest lot line----------------- 0 Number of pits______________________Lining material-----------------------Size: Diameter------------------------Dept h_______-________________________- 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----------------------------•-------------------------------------------------------------------------------------------------------------- (� "V Re od ng a epa ring escnbe): •---------•------------------------------------------------------------------- - ---------- -------------------- ----------------- ••--•----•- -----•••••----- I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State la s, 'and rules and regulations of the San Joaquin Local Health District. (Signed)-- -- -----------------Cam - - -- -----------------------------------------------------------------------------------------(Owner and/or Contractor) B ------------------------------------------------------------------------------------------------------------------------------------(Title)---------------------------------------------------------------- (Plot pi , 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_ ---- -------------------------------------------------------------------------------- DATE__/,_ --------------------------------------------------- REVIEWEDBY----------- ------ ----- - ---------------------------------------- --------------------------------- DATE BUILDINGPERMIT ISSUED--------------------------------------------------------------- ------------------------------------- DATE---------- ------ - Alteratigns and/or recommendations: ____ _ t __ ----------------- ------------- __ ____ s I �_ -,, --------- - -- - -- - - ----- ----- --- ---- - --- ------------ _.._._ -----------• ----------------- - ---- < ---------- --------------------------------- - ---- ---------------------------------•-----------------------------------------------------------------------------------------------------------------------•----------------------------------------------------------------- ---------------------------------------- --------•-•------------- ---------------------------------------------------------------------------------------------------------------------------------------------------- ---------------------------------------------------------------------------------------------------------------- ----------------------------------------------------------------------------------------------------------- FINAL INSPECTION BY: -f--k--------------------------------- 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 8-51 Revised W-2100