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'9Permit 1 g APPLICATION FOR SANITATION PERMIT (Complete in Duplicate) Da+e Issued -- -------- sY Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described. i This application is made in compliance with Count Orkance No. 54,9i JOB ADDRESS NE) LO - Tl - - ----- -------------------- Phone__0__`"-_ _ r� -- -t-•- - Owners Name �"_ ____-_----'--- ------------'-------------------------------- Address - --- ---- - ------ - - - - Contractor's Name--------- Phone----------------------------------- Installation will serve: Residence 4( Apartment House Commercial ❑ Trailer Court ❑ 'Mo/t�u ❑ Other ❑ • -___ Lot size --- --1�---��_� -------Number of of living units: _Xmmunity mber of bedrooms _�__ Number of baths _ _ Water Supply: Public system system fl Private ❑ Depth to Water Table :Q ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam Clay Loam El Clay ❑ Adobe�ardpan E)licati Previous A MadYes ❑ No I/ New Construction: Yes VNo ❑ Application e: � F TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) erptic nk: 6 Distance from nearest well----------------- from foundation--------------------Material------------------------------------------------- No. of compartments---------------------------Size--------------------------------Liquid depth-------------------------Capacity------ a Lisp sal Fi 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__-________________f__"_Depth of filter material--_.__________ Total length__________________________-__ ---- /}g� Distant royn fo dation �Dist re to nearest lot,�ine Seepa Pit: Distance to nearest w Il-:._ 0.0.__. r Number of pits---------- --------Lining material1ize: Diameter-----�' ----------.Depth------ - ------- Cesspool: Distance from nearest well_________-______Distance from foundation-------------------.Lining materia___________________-----------""als. ❑ Size: Diameter----•---------------------------------Depth----------------------------------------------------Liquid Capacity--------------------•-------g r Privy: Distance from nearest well-------------------------------------------------Distance from nearest building---------------------------------------•-- ❑ Distance to nearest lot line--------------------------------------- - ----•----- ------ --------------•---------------------------------------•----------------------- - - Remodeling aid/or repairing (describe:------.-------------------------------------------------------------------------------------------------------------------------------------------------- --------------------------------------------------------------- I hereby certif that I have prepared this.application and that the work will be done in accordance with San Joaquin County ordinances, S e a_ s, and rules and regulations 6 the San Joaquin Local Heal+h District. Signed _1----------------------------- ---------------------------------------------------------------------------------------------- _____________(Owner and/or Contractor) By:-------•--------------------------•--------------•-- -- - - - ------- (Tit e) (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 DATE-- APPLICATION ACCEPTED BY_ __-__----------------- ------------------------------ ------------------- REVIEWEDBY ---------------------- -------------------------------- DATE " BUILDING PERMIT ISSUED---------------------------------------------------------------------------------- DATE Alterations and/or recommendations:_._______._-_._.._- ---------------------------------'-----`--"- -' " - --------------------------------------------------- ------------•-------------------------------------------------- --------------------------------------------------------- _--------_---------------_-------------------------------------------------------------------------------- FINAL INSPECTION BY----------------- ---------------- Date------------ C �` SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 3oo 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