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- 1 / APPLICATION FOR SANITATION PERMIT Permit No. _T. ._.._ .__...... (Complete in Duplicate) Date Issued Application is hereby made to the San Joaquin Local Health Distri :ora permi to c nstruct and install the work herein described. This application is made in compliance with Cou ty Ordinance N . 5' 9. JOB ADDRESS AND LOCATION- - --- ------- ---- i------ ----- ----'i ---- ----------------- ------------------ ------p-------------------- Owner's Name---•-----------------------.... .... ------/----------- � ... - Phone.-�-Q__ C.'e: Address--------------------------------- �:��'�----- Contractor's Name------------------------------------ Phone. Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ i e � Number of living units: __ ___ Number of bedrooms__ Number of baths ---4__ 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 ❑ Sandy Loam ❑ Clay oam ❑ Clay ❑ Adobe Hardpan ❑ Previous Application Made: Yes ❑ Noe New Construction: Yes ❑ No �]d �t TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) ' r S ick Distance from nearest well-________________Distance from foundation------------------- Material--------------- ---------.----------.-_._____-__-p,�� f No. of compartments-----------,�--!------------Size--------------------------------Liquid depth---------- ----------- ---Capacity------------------ W p rom nearest wellA—1_._.Distance from foundation---'_�--r.--.Distance to nearest lot liner��_'"- Dis� Field: Distance from lines________ y- ______-_Length of each line___s -r�__ Number or ___-_�._ �_- __ _ .�f______.Width of trench.__,eat.__��____ _______________`� Type of ftI`er material__�__'4�__i A-_____Depth of filter material-____�.�.._______Total length__�-� ____________________________ V 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---.--------------- Lining material------------------------------.____-_ ❑ Size:"Diameter---------------------------------------Depth---------------------------------------------------Liquid Capacity------------------------ -gals. Privy: Distance from nearest well------------------------------------------------- from nearest building--------__.__._______-_-______..____---.-. ❑ Distance to nearest lot line- ------ } L Remodeling and/or repairing;'(describe)----------------------------------------------------•---•------------------•------------------- ---------------•---------------------------------------- -----------------------•------- ---------- ----•-------------------------------------------••----------•-----------------•---•------•---•-•-----------------------------•----------------------------------------- ordinances, laws an- have ----------------------------• -----------•-• --------------------------------------------------------------------------------�--- ------- - - - - --- _ hereby y p are 1this application an that the work will_be done in accordance with San Joaquin County les d re kflation' f the San oa u n Local He Ith District. 3 (Signed)------------------------------ -�---- - - ------------- ----- --r--- -- ------ --- ------ (OwrMmiar►d Contractor) B •----------------------------- --;'._ . . ... . - - ----- Title his+ t i . Y• - ( � ) (Plot plan, showing size of lot,;location of system in relation t els, buildings, et� can be p- on reverse side). FOR,DEPAkTMENT USE ONLY APPLICATION ACCEPTED BY------------------- ,-- __-- - f -- -•----------- DATE------- REVIEWED BY--------------------- ---- -- -- --------- - -------------------------------- ----------------------------------------------- DATE--------------------•----• --------------------------------- BUILDINGPERMIT ISSUED----'I'---------------------------- ------------------------------------------------------------------ DATE------------------------------------------------------------- Alterationsand/or recommendations---------------------------------------------- --------------------------------------------•----------------------------------------------------------------- F --------------------------------------------------------------- -- --- ----------------------------- ------------------------------ FINAL INSPECTION BY:-.--�------------ -' Date - 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 10-52 Revised W-2100