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APPLICATION FOR SANITATION PERMIT F Permff No c� I --..-r----------I---- (Com p ete in Duplicate) / �{ Date Issued Application is hereby made to the San Joaquin Local Health District for a permit to construct a install two; erein described. This application is made in compliance with oun Ordinan�c�` JOB ADDRESS AND LOCATION—_ / �� OwnersName_ — --------------•--- --------------------------- ------------------------------------ -- ------ --- ------------------- --------- ---- ----- - Phone------------------- ontractor's Name-_____ Installation will serve: Residence p --------------- Phone------- A artmenfi House [] Commercial • Number of livingunits: !_ ❑ Trailer Court ❑ Motel � Other ❑ f-- Number of bedrooms �- Number of baths �_ Lot size i Wafer Supply: Publics stem ❑ ''�'�� F Y Community system R2"rivate ❑ Depth to Water Tableffi- Character of soil to a depth of 3 feef: Sand [( Gravel ❑ Sandy Loam ❑ Clay Loam E] Clay I Previous Application Made: Yes Y ❑ Adobe CC Hardpan [] [] No ❑ New Construction: Yes ❑ No El FHA/VA: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or'cesspool permitted if public sewer is available within 200 feet.) Septic Tank: Distance from earest well --------Distance f om foundation_ a--- No. of compartments_____ __ ---------------Size-- �� Mer a!-_�- f_ -' -�_� -Liquid depth ---- _-. } Disposal Field: Distance from nearest well__. ----__-_.Distance from foundation__.• ice_ Capacity_-- . ------------ Number of lines_ .--_. _ - Length of each line_--___7 Distance to nearest lot line___-�___ ' Type of filter material - - -. Width of trench__-v?- -- Depth of filter"material-_/�j!- ------Total length_------1,!� --------------------- Pit Seepage : Distance to nearest well__-__-_,'_ - Disiance from fo anon_-._ Q�____.c ista�e to nearest lot line -------- ------Number of pifis4---_--_-_.-Lining material u/�/ -- ,L- - ---._z_Size: Diameter_...�i--_ � � Cesspool: Distance from nearest well-------------- ------Depth_____._____._--_____ Distance from. Lining material_____-_-_---_ Size: Diameter--------- ------- ------- -----------Depth-------------------------- - -------------------- ------------------------- ------------------- -- ' --Liquid Capacity.-------------- Privy= distance from nearest well.____.____-_- -----------gals• ---------------------------------Distance from nearest building❑ Distance to nearest lot line------------ -- g ------ 'Z ---------------- ----- - ------------- f w ---------------- ' Remodeling and/or repairing (describe):------------- ---------------------- ---- `�i�� - - ------------------------------------------------------ ---- ---------------------- ------------------------------------------- -------------•----- ----- ---- on and that the work will be done in accordance with San I hereby certify that ! have prepared this applicatiiJoaquin County ordinances, State laws, and rules and regulations of the San Joaquin Loca Health District. Y (Signed)-------------------- By: ------•----------- — 4 �= --------------- ark or Contractor BY�------------------- ----------------- -� I R (Pl of plan, showing size of to cation of system in.relation to wells, buildings, etc., .can beleplaced on reverse side). +iI FO DEPARTMENT USE ONLY APPLICATION ACCEPTED BY-------•--------- REVIEWED BY DATE ' - ------------------------- BUILDING PERMIT ISSUEDv --- ----------------- DATE-- -------- DATE -------- Alterations and/or recommendations__________________ _� ------------------------------------- -------------------------------------------- ----------- _ __ --------- ----------------- -- ------------------•---------- ----- -------- FINAL INSPECTION BY:-------- � t Date ; - -- - ------ � .7 SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 30D West Oak Street 132 Sycamore S+rent 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California J� E5-9-2M , Revised 1.57 F.P,CO. f