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i r APPLICATION FOR SANITATION PERMIT Permit No.cj•_3_____I___ (Complete in Duplicate) � � �Sy 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 C my Ordina , e No 5 , --- -•------------------------------------------------- --------------------------- JOB ADDRESS A L�/ATI ------&--19 - --- --- ---- ---------------------- - Owner's Name ----- Phone ; Address-------;�-- - ---- --- ---- - -------------------------------------------------------------------------------------------------------------------------------------------------------- Contractor's Name-- ------------------ ---------------------------------------------------------------------------------------------------------------------- Phone----------------------------------- Installation will serve: Residence g/ Apartment House ❑ Commercial E] Trailer Court [—] Motel E] Other F]rr `` 1 Number of living units: -----!__ mber of bedrooms -_�_ Number of baths .__!___ Lot size ___________________________ Water Supply: Public system Community system ❑ Private ❑ Depth to Water Table ________ ft. Character of soil to a depth of 3 feet: Sand _ Gravel E] Sandy Loam Clay Loam ❑ Clay ❑ Adobe�ardpan E]Previous Application Made: Yes ❑ No New Construction: Yes ;"No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if pu I'l!��sgwer is available within 200 feet.) i Septic Tank: Distance from nearest well__ V___-Dista ce fro_U jou�a�ion---�_o--------Matle�'aj---611�_________--- ----------- __ h _ No. of compartments------------ - ----}--�-Size- ---7--�-- X---------Liquids dept(s-------'�1�------------Capacity----- d/- ---- No. of os Field: Distance from nearest well_ !!_'-_Distance from foundati fsf-/___ _ D'sstance to nearest lot line ---------- p Number of lines____________ ____ Length of each line��_ _ �"� Width of trench--------------- T Type of filter materi f yp a + _ - -----f}epth of filter material------/- 1----------Total length---------- -�t1 ----.•----.-----•. Seepage Pit: Distance 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-------------------- material-------------------------------------- ElSize: Diameter--------------------------------------Depth---------------------------------------------------Liquid Capacity---------------------------•gals. Privy: Distance from nearest well-_______________________________ -------------Distance from nearest building___.______.______---____-_-_--------___-_. ❑ Distance to nearest lot line-------------------------------------------------•------------------------------------------------------------------•------------------------- Remodeling and/or repairing (describe):-------•-----------------------------------------------------------------------------------------•--•------------------•------- -----•- --------------•-------------------------------•----------------------------------------------------------------------------------•-------------•----------------------------------------------------------------------------- I hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, ate laws, nd rule d regula+i the San Joaquin Local Health District. 5i ned _u- , ______._-__Owner and or Contractor( g ) ( I g (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 ` REVIEWEDBY--------------------------------- -- - ------- - ------------------------------------------------------- DATE---- ------ BUILDING PERMIT ISSUED------------------------------------------------------------------------------------------------------ DATE---------------------- ------ Alterationsand/or recommendations:---------------------------------------------•------------------------------------------------------•---------------------------------------------------------- ---------------------------------- --------------------------------------------------------------------------------------------------------------------•----------------------------------------------------------------.--- ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ---------------------------------------------- ---------------------------------------------------------------- ----------------------------------------------------------- ------------------------------------------------ i FINAL INSPECTION BY:------- --- - Date_.. -- -.'I T 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-4-2M 8-51 Revised W-2100