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q APPLICATION FOR SANITATION PERMIT Permit No. (Complete in Duplicate) _ Date Issued )llii �Application is hereby made to the San Joaquin Local Health District fora ermit to construct and install t This application is made in compliance with CountyOrdinance N P he work herein described. /QC� JOB ADDRESS AND LOCATION_____----------- __-___ ,_____-_: 1 Owner's Name ---------------- ------------t� Phone_ oo Address-------------- Contractor's Name t 4 ------ Phone -9-- ---1- ----- Installation will serve: Residence jo Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: __/__--__ Number of bedrooms _y_ Numb r of baths [----- Lot size ------ _ -A--------------•-_-----------_-_ Water Supply: Public system�Community system '❑ Private �to Water Table 40�__Cp ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam F1 Clay Loam ❑ Clay ❑ Adobe; Hardpan ❑ Previous Application Made: Yes ❑ Noj&, New Construction: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public 1Pwer is available within 200 feet.) �eptic Tank: Distance from nearest well__`-----Distance from foundatior �_____-Material ____1 �i ##If _ ----------------- ,No. of compartments-'V__________________Size�k�X, // � ---Liquid depth__+ .2---------------Capacity--la , 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------------------------------------------ cSeepage Pit: Distance to nearest well,/-P,6' �___- -____Distant fr ou ation__C _____.___.Distance to nearest lot line./ 40-1, Number of pits----/_____________Lining materia _ _ _Size: Diameter___,.�3" * Depth"' 'r esspool: Distance from nearest welL______________Distcince 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 ---- --------------------- `tel G" A--- �- ,,.-- . .,.. _______________________________________________________________________ -----------•------------------ --------------------------------------------------------------------------------------------------------------- I hereby certify that I ha repared this appl' ation and that the work will be done in accordance with San Joaquin County ordinances, Stat law , nd rules nd' regulations f the San Jo quin Local Health District. (Signed)-- t caner d/ r Contractor) ----------------------------------- Y� --- ----- -- (Title) i (Plot plan, sho ing size of lot, location f system in relation to wells, buildings, etc., can be plac'"ed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY \ REVIEWEDBY ---L-------------------------------------------------------------------- DATE--------------- ---------------------------------------------------------- -------•---.._.._: - ------------------- ---------------------------------------------- DATE PERMIT ISSUED--------------------------------------------------------------- -- DATE ------------------------------------•----- ------------ -- Alterations and/or recommendations_________________________--___ ----------------------------------------------- -- FINAL INSPECTION BY:----- --------------__ _______ f Date f r 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