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APPLICATION FOR SANITATION PERMIT Permit No. (Complete in Duplicate) _ �� S 3 c 1 Date Issued -_--- ----...•'-_----_ pplication is hereby made to the San Joaquin Local Health Distric or a permit to construct and install the work herein described. This application is made in compliance with County OrdinaZNoJOB ADDRESS AND LOCATION_______-_ I-� Owner's Name------------------------------------- •�Lc n ---._. Phone---�-7:4*4V -.---- Address Contractor's Name--------------------------------------- _. - -------------------------------------•-------------------- Phone------- Installation will serve: Residence ®, Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ i Number of living units: .____ Number of bedrooms ________ Number of baths -------- Lot size --x_..-/--0_----- Water Supply: Public system IX Community system ❑ Private ❑ Depth to Water Table __��ff. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe® Hardpan ❑ Previous Application Made: Yes ❑ No Dd New Construction: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Sis T nk:` Distance from nearest well-----------------Distance from foundation--------------------Material--------------------- _________________._. � '^ I No. of compartments--------------------------Size-------•--•-------------•-------Liquid depth------------ -------------Capacity---------------------- q` _ DopOsal Ick.- Distance from nearest well------ _______Distance from foundation--------------------Distance to nearest lot line________________� C`0;� 4 Number of lines----------- ---- Length of each line------------------------------Width of trench. t,' Type of filter material_________________________Depth of filter material-____________.__..__-Total length-------------------------- `^' ---------------- Seepage Pit: Distance to nearest well__M4_M_=_____Distance o oun ation_ well--MOA� __ _ ________Distance to nearest lot line____f Number of pits__._______________Lining material _ . Size: Diameter__j_3_�'__-_-__Depth-._- '��'r ----- 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---------------------------------------- El Distance _--_..__.___.____--__------------------Distance to nearest lot line. ------------------------------------------------------------------ Remodeling and/or repairing (describe):----------------------- -------------------------•--'-----------------------•-------•- -----------------------------------------------------•---••----------•-------------------------------------------------------------------------•-------------- q Y I hereby certify 1 have prepared this application and that the work will be done in accordance with San Joe uin Count ordinances, State la nd rules and reg tions of the San Joaquin Local Health District. (Signed) -- --- 4/ - ------------------ ---- --- --- Contractor) By--------••----------------------- -- (Plot plan, showing size of lot, location of system in tela io wells, buildings, c., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY---------------------------------------------- DATE------------ ---------------------- REVIEWEDBY----------------------------------- --- --------------------------------------------------------'�'--j------------••---------------------- � �a -- --- ------------------ DATE----- --•------- -- -------- ------------------------------ BUILD1NG PERMIT ISSUED-------------------- ---------------------------------------------------------------------------------- DATE Alterations and/or recommendations________________________ ._ ---------••---•-------------------------------•-------------------------•----------------•---------------------...-----------------------------------------------------— -------------------------------------------------------------------------------------------------- ---------------------•-------------------------•-------•-•-- -------•----------------------- FINAL INSPECTION BY-------- --- ---- -z Cf' ----- Date.-- -------------- SAN ----------- vSAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Sfreet 132 Sycamore Street 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California ES--9—•2M 0-52 Revised W-2100