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APPLICATION FOR SANITATION PERMIT Permit No. (Complete in Duplicate) ' S� d 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 Or, 'nance NoId—, JOB ADDRESS LOC ION----- /-Z - "•• ---------------------------------- ---------------------------------------- Owner s Name__"-- IC"_ -- n Phone I ----------------------- Address------cli... ._-. i• ' Contractor's Name--- ------- -----•---- -------------- Phone I Installation will serve: jResidence Apartment House Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ -t Number of living units: ---/---,Number of bedroom _ s __-1--_ Number of of "-�___ Lot size ______________ ___� Water Supply: Public#system sy Community system ❑ Private ❑ Depth to Water Table ____-_-. ft. Character of soil to a depth of 3 feet: Sand E] Gravel ❑ Sandy Loam 0 Clay Loam ❑ Clay ❑ Adobe 2/Hardpan ❑ Previous Application Made: Yes ❑I No [/,NewConstruction: Yes No ❑ �K • . ,`' ' TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tank: Distance from nearest well______________'Distance from foundation--------------------Material _-____.-__""___ No. of Disposal Field: Distance from nearest well__ - ---------�D'stance from fbr Liquid depth______________-"-""___""Capacity----------------""""-- compartments �j i undation______.-"---_______.Distance to nearest lot line________________" ' ❑ Number of lines----•-----------------------------b Length of eachlline-_----------------------------Width of trench-.-------------------------___-__ i Type or filter material------------------------- of filter material----------------------- _ otal length--I------------------------- Seepage Pit: Dist"�nce`to'nearest well':`_-_-" "".____Distance from foundation--------------------Distance to nearest lot line_-__--- Number of pits----------------------Lining material------------------"---.Size: Diameter------------------------Depth------------------- ""-- -- Cesspool: Distance from nearest well-----------------Distance from foundation-------------------.Lining material______-__--_----_______--_._--" Size: Diameter---------------------t. D�epth_ ----------- ----Liquid Capacity.;----- I-----------------gals. r --------------- ----- - - Privy: Distance from nearest well" __-_._ ..- ------------Distance from nearest buildin _ Distance to nearest lot line-------- -- ------------------ ------------------------ -- Remodeling and/or repairing {describe)____________________ . P ------•-----------•--------- -------------------•---------•-•--------------------•----------------•--•---- �.._ •---------- -------------------------------------------------------------------------------------------------•------- ---------------------------------------------------------------------------------------------------------------- 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 ules and regulations of the San Joaquin Local Health District. (Signed) -- - -------- ..-------- -- -----------------------(Owner and/or Contractor) I By:.:----� -�� r= ------ .--{Title) (Plot plan, shai size of lot, Iota+ion of syste m elation to wells, buildings, etc 'ce placed on reverse side}. FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY - --------------------------------- -- --------X------- "-----71- 5�71YATE---------------------------- ---------------------------------- ---------9- REVIEWED BY ------- ---------------------------------------------- ---------Fe----- ;--t•z= .DATE BUILDING PERMIT ISSUED -------- `-------------- DATE------• - - - ----------------------- _____ _ A{tor tions and/or recommend __ __________ '`�- s -------------- - .- _ - Q . _ { -------------0 "-- - ---r ` r ----------- ------- Yedl-f--.:�_�4------- 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 �0-52 Revised W-2100