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;APP!!(CATION- FOR,SANITATION PERMIT Permit No. -- -------------- ' (Complete in,Dupl'Icate) N Date.Issued Applica-lion is hereby made to the San Joaquin Local Health District fora permrt;to construct and ins+all the work herein described. This application is made in compliance with County Ordinance No. 5 9. . JOB ADDRESS AND LOCATION------ ------ i{7.---- ------ ------------ ------ Owner's Name.----- # �---- .. ..f ------------- ------------------------ ------------------- Phone------------------------------------ R Address------ //......... f i Contractor's Name. --------------------------- - ---- Phone.--.------------------------------ Installation will serve: Residence Apartment Hou e,❑ Commercial,❑ Trailer Court ❑/ Motel ❑ Other ❑ (Number of living units: .__- Number of bedrooms . Number of baths ___ Lot.size _/ __ __ -_ ---- _-:---___--_ I, _ 0. 1 Water Supply: Public system ❑r Community system ❑ Private. Depth +o.Water Table _______ ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑5•and.y Loain,X Clay Loam Clay ❑ Adobe ❑ Hardpan ❑ Previous Application Made: Yes ❑ iNo Im New C nsJftuction: Yes No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if 1 public sewer'is available within 200 feet:) b._ 1 _.� k , Septic:Tank: Distance from nearest well__ Distance from foundation_� _..Materi . " 1___ e --- -_-Capacity_ No: ty_Noof compartments _ �, - _Size_ " - Liquid d _k Disposal Field: Distance from nearest well -----Distance from foundation-__ - Distance to nearest lot line_ Number of lines_______`. g �Q_--____ __. Width of trench___.. _______________�--Length of each line___ _ Type of filter material ? Depth of filter material-_______._.L. .__-._Total length______ ,( _ _____________ Seepage Pit: Distance to nearest well-_____.________________Distance from foundation_._...._________-_..Distance to nearest lot line_______.__- ❑ Number of pits----------------------Lining material-_---------------------Size: Diameter--- ---------_.Depth--------------------------------- }F Cesspool: Distance from nearest well--------___•-____Distance from foundation___________________ Lining material__._---___.___._____._ ! Size: Diameter- .. -------------------------------De th--------------------- ------- -----------------------Li uid Capacity------------------------ Privy: -----Privy: I Distance from nearestbuilding well-------------------------------------------------Distance from nearest building--------.-------------------------------. l ❑ -Distance'to nearest lot line-------------_-------- .__--- ------------------------------------------ f :--------- ------------- ------------------- ---•---- Remodeling and/or repairing (clescribe)---------- --------- ------ mP 1 ----- ----------------------------------------------- -------------------------------------------------------------- ------------------------- ---------------- ------------------ 1-•------------•-------- ------------------------------------•- ------------•----------------------------------------- ---------------------•----•-----------------------------------------------•----------------------------------- 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 a regulations of the San Joaquin Local Health District. (Signed)-"--- By: Signed} ------- -----s----------------- --- --------------••-------------------------------------------------------(Owner d/or Contractor) By:---- -- ----- ------- ---------------------------------------------------------- --(Title)---- ------------- -------- Plot Ian, sho In size o to , ocation of s stem in relation to wells, buildings, etc., can be laOer�o�P 9 yg , pn reverse side}. FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY--------------- -- - ---------------------------------- '.-..- DATE---------- REVIEWEDBY --•-------------------------------- --------------------------------------------------'----- ------------------- DATE-------- - F-- V BUILDINGPERMIT ISSUED--------------------- ------•------------------------------------- --_------------------------------ DATE-------------------------------------------- Alterations and/or recommendations----------------= ------------ --------------------------------- ----------------------•-----•.•--------•-----••------------ ----------------------------------------------------------------------------------------------------------------------------------------------------------------•------------•------------ ---------• --------------------•---•-------•-------•-----------•--------------- ---------------.:.-------------------------------------•-----•- --------- -------------------___________________________________________________________________________________________________________t_--.----------------------------------------------------------------- _ --------------------- ---------------------------------__________---------_-----------------------_--------_-----------------------_________________________________________________________________________________ ' FINAL INSPECTION BY:------ _ .I!L, 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 Revised W-2100