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l APPLICATION FOR SANITATION PERMIT Permit (Complete in Duplicate) f 0 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 compliance with County Ordin e No. 9(:0_6 JOBADDRESS D LOC TI --------- ------------------------------------------------------------------------------ Owner's Name_ • ---- - ------ - --------------------------------------- -------------------------------------------- Pone--------"""' ----------------------- Address--- -- -s2��? ._ t.-___--- ----------------------------------------------------------------------------------------------- -=------------------------------------------- Contractor's Name--- ------- --- ----- - -------------------------------- Phone----------------------------------- -- ------ -- --------- ------------------------------- Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ ote) ❑ Other El Number of living units: j--- Number of bedrooms _Z_ Number of baths -/---- Lot size ----- ___!1__------X•- G3?-p-------------------- 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 E] Clay ❑ Adobe/Hardpan ❑ Previous Application Made: Yes El No New Construction: Yes [ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: ` (No septic tank or cesspool permitted if public sewer is available within 200 feet.) R Septi ank: Distance from nearest well "__'_~__ Distan fro foun�ion___ _ __-Materi Lf____ _________ - No. of compartments____. ---�--------__Size_________x_ _X_ Liquid depth---------- Disposal Field: Distance from nearest well ' Distance from foundation__ _Z__I Distance to nearest lot lin _ S5 T --------- 52( Number of lines___________ ________ Length of each line-------__�__�-Q Width of trench _ � Type of filter materi - _-, epth of filter material-------- ______.__Total length___________ _ --7 Seepage Pit: Distance to nearest well----------------------Distance from foundation_.___________-__-.Distance to nearest lot line_________________ 1 ❑ Number of pits----------------------Lining material-----------------------Size: Diameter------------------------Depth------------------- 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 - 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 regulations of the San Joaquin Local Health District. (Signed)- BY: ate'" ,r ter ' ------- -- --------- -- --- -- ------- _____(Owner and/or Contractor) - 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___ `' DATE___ ------------------------------------------------------------------------------------------- REVIEWED BY_______ ------------------------------ ------- ------------------------------------------------------------------------- DATE--------- BUILDING PERMIT ISSUED--------------- ` ---------------------------------------------------------------------------------- DATE ----------•!"'". Alterations and/or recommendations:__. Qf `- y� --------------------------------------------- ----------------------------------- FINAL INSPECTION BY:------- - 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