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APPLICATION FOR SANITATION PERMIT Permit No. (Complete in Duplicate) Date Issued __''1 Applica-i-ion 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 Ordinance N 9. JOB ADDRESS AND-LOCATION--------------- +'1 - Owner`s Name ; �--- •`- �/�71 ,v ... Phone----------------------•---------••-- Addressf-� ` ---•-•------------------------ f Contractor's Name----- / � /l -i//� ----- .•6 `t Phone., _--'tal Installation will serve: Residence D,"`Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: _)____ Number of bedrooms-_'_�_. Number of baths ___/___ Lot size ------- _.�`�________________----- Water Supply: Public'system_0 Community system ❑ Privete.JRL Depth to Water Table . . ft. Characterof soil to a depth of 3 feet: . Sand ❑ Gravel [❑- Sandy Loam ❑ Clay Loam El Clay E] Adobe[3\ Hardpan [I Previous Application Made: Yes E] No 2t New Construction:Yes ❑ No j&, TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic y Tank: Distance from nearest well-------------___Distance from foundation___________________Material-------______.______.___-____________________. . No. of compartments-------------------------Size----------------•--------------..Liquid depth------------------------Capacity----------------------- 1 t + �r"7 [ r Disposal Fib '� Distance from nearest well- Distance from foundation____--, ____.Distance to nearest lot line______ _______ OQ ® d- Number of lines_____p._.____1 --____._. Length of each line--------- Y� ~ ;•r.„Width of trench________;20�-------------- N Type of filter matenaL__/_ ---__`�,___ __Depth of filter material------- ---------Total length ______--_.__ Seepage Pit: Distance`fo' 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--------------------------------------Depth-----------------------------------------------------Liquid Capacity----------------------------gals. Privy:' Distance'from nearest well-------------------------------------- ---------------Distance from nearest building______..._,------_____._________________ ❑ Distance'to'nearest{lot` ------_----------------- - �. . ------------------------------------------------------ air1 descand or r -Remodeling -___ - / ! ` t _ -e� _}-•_-----= - y _---------- ------------------------- - # ------------------- ------ ------- -- ----- ' --- -------- --- ---- --- --- ---------------- - ----- ._ -------------------------------------- --=--------- ----------------- I,hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, St e a s; and rules and regulations of the San Joaquin Local Health District. P (Si ned g )------ -------- -------•-- ------ _ Owner and/or Contractor) By:. -.rr - �' = Title - ---- -------------------------- (Plot plan s owing size of l t, location system in relation to wells, buildings, etc., can be place reverse side). 'FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY-------- = � ._, DATE = fi- ----- -------------------- -------------------------------- ------------------------- REVIEWEDBY---=------------------------------ ------------------------------ --------------------------- DATE - .. BUILDING PERMIT ISSUED------------------- "-------_---:---------------------{---------------------------- DATE-------•----- . Alterations and/or recommendations------------------- ------ --`------------.--- ----•--------- ----- .....fir ---------------------------------•------------•-------•-------------------------------------------------- - -----------------------------------------------------------•---•------------------------•-•-------------------- ----------•--------------------------------------- --•=-- --` ---- -- FINAL INSPECTION BY:------ d___ `-1.= ---=-- Date--------- '... _ _ s.._.__ ----------------------------- 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 ; Revised W-2100