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APPLICATION FOR SANITATION PERMIT Permit No:,___ .......l ....it ' 1 (Complete in Duplicate) °_ ��—•a :S, ke Date Issued A lication is hereb made tSan Joaquin Local Health District fora pfmit to o' tru t and install the work herein described. This application is made in compliance. with County Ordinanc No. JOB ADDRESS D L C T ON-- ---" _C �� ?O Off'. --._L ._.. f C ' Owner's Name.. = ------ ---------------------- ----------------------- ------------------------------------- Phone.....e-1 Address _.. ------------------------------ ------------------------------------------------------------ -.. Contractor's Name---- ----------------- - - -_------___--__--__ Phone_-__--- ---- --------------------------------------------------- Installation will serve: ResidenI---- Apartment House ❑ Commercial ❑ Trailer Court ❑ M t I ❑ Other ❑ ,p Number of living units: Number of bedrooms-__ Number o baths __��__ Lot size _�J�`�'�=��---------��'._____.__ Water Supply: Public system ❑ Community system ❑ Private Depth to Water Table ------_ ft. Character of soil to a depth of 3 feet: Sand F]Gravel Sandy Loam Clay Loam ❑ Clay ❑ Adobe 2'-/Hardpan E]Previous Application Made: Yes E] No New Construction: Yes o ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) /1 Septic ank: Distance from nearest well V.19--Distance from foun tion___--` -___-Materi I .'.____ __ No. of compartments----------- _________Size_ __Xc _X __Liquid dept ---� -_____ Ca acitQ_O i }� p Y Dispos Field: Distance from nearest well_ __ --Distance from foundation------__. -_ Distance to nearest lot line ---------- Number of lines-----______ I -_�ength of each line_________________ %____-Width of trench t_-____----_ Type of filter materia fi! `------ p g th of filter material____._�_ _ _.__Total length ___- ___ __Q________________ Seepage Pit: Distance to nearest well___ ______________Distance from foundation....................Distance to nearest lot line----------------- El _-___ -__-_____❑ Number of pits-- ------------------Lining material------------------------Size: Diameter------------------------Depth--------------------------------- Cesspool: _-._-____________-___ ____-___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--------------------------------------------------------------------------------------------------------------------------------- ------ Remodelingand/or repairing (describe)-------- ------- ----------- ---------------------------- ----------------------------------------------------------------------- ------ ------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------- ............. -------------------------------------------------------- ---------------------------------------- -------------------------------------------------------------------------- --------------------- ------------------------ ------------------------------------------------------------------------------------ -------------------------------------------------------------------------------------- ------ I hereby certify that l have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State I ws, and rules and regulati ns of the San Joaquin Local Health District. (Signed)------- -- --------------------------------------------------------------------(Owner and/or Contractor) By:--------------------------------------------------------------------------------- --- -------------------------------- ----(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 BYV ----- ----- -------------------------------- DATE ---------------- REVIEWEDBY --------------------- --- ----- --------------------------- DATE a' -------------------------------- BUILDING PERMIT ISSUED--------- -------------------------------- ----- ------ DATE_ '� Alterations and/or recommendations_ ___________ ` __ r�------------------------- ..........................................-- ------ ----- --- -- ------- - v c� �y) - ee------- ,,� c 8� �a __________________________ .------ ______._._______ _ ____________ __ ___ --r 1 � -'/ d/l ----------------------------------------------------------- ---�1�-�------_ / 1 -----------------------------------------------. ._____________ _. _.__.__ _____- __.. -____ _ _---_._ '� ._._-_ ___-__-- FINAL INSPECTION BY:--------- ---- -- ------ Date.-------------/Z *5 ---------------------- 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 8.5.1 Revised W-2100