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APPLICATION FOR SANITATION PERMIT Permit No. h (Complete in Duplicate) Date Issued Application is hereby made to the San Joaquin Local Health District fora r to cogs ruct and i all the wor rein described. This application is made in compliance ith County Ordin No. 49• { JOB ADDRESS LOCATIO jt - -- ---- --�-- ------Z`-- Owner's Name--- = = _ Y ---- --- ----- -- -- -- ------------------------------------------- Phone - --------------'---- ---Address--------- � f7 _ Contractor's Name------------ -------------------------------------- I------------------------------------------------------- Phone----------------------------------- 1 Installation will serve: Residence.;.Apartment House E] Commercial ❑ Trailer Court ❑/Motel ❑ Other ❑ Number of living units: _-/-_-_Number of bedroomsu--- Number of baths ___r__ Lot size -__(Q ___ _ _�P-�------------_-----_----- # Water Supply: Public system Community„ sygtem ❑ Private ❑ Depth to Water Table -.q- ff. i Character of sail to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy+Loam ❑ Clay Loam ❑ Clay E] Adobe Hardpan ❑ Previous Application Made: Yes ❑ No 2111” New Construction: Yes []"--No ❑ FHA/VA: Yes ❑" No TYPE OF INSTALLATION AND SPECIFICATIONS- - (No septic tank or'cesspool permitted if publ' sewer is available within 200 feet-) r Septic ank: Distance from nearest well-_____s�uistan from foundation----/�__-_-----.Ma rial_-_a�apaci ___________ xJ x _- No. of compartm n#s Size Liquid depth ty Dispos l'Field: , Distance from nearest well_- IJ►s�/visfance from foundatio _ID_.._.._._..Distancelto nearest lot line----------------- 74 _---cam.-- Number of lines__ __ __ _ _ ._.____ --_Lengi�h of each line—__ C?____- Width of trench.___,__ f_ .. - . �_ ._.,_--_._ - --y �j - /------------------ Type of filter material__ . --Depth of filter material___._1 -------------Total length_____c��G____-_______-____-__-- Seepage Pit: Distance to nearest welt----------------------Distance from-•foundation-------------------.Distance to nearest lot line__-._____---____ \ ❑ Number of pits----------------------Lining*material---------------------..Size: Diameter-----------------------Depth_-------------------------------- is� Cesspool: Distance from nearest well__________ ___Distance from foundation------------------- Lining material___.____._.__._______.____________ ❑ p Size: Diameter--------------------------------------De th_---- -------------i-- -- -- Liquid CapacitY -------------gals. Privy: Distance from nearest well__________________ ______________ ------------I.-Distance from nearest building___-_-__-----------_____---_____._----- ❑ _ -- s Distance to nearest lot line_- ---'- --------------- --------------------------------------•--------------------- ------------------------------------------------------ Remodeling and/or -repairing (describe)_-------------------------------------------------- ---------•-------- ----------- _ i ; --------------------------------------- --------------------------------------- -------- i--- `- I hereby certify that lAave prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State laws,'an,8 rules and regulatio s of tate San Joaquin Local Health District. K I (Signed)---- ---------------_:-------------------------------------------------------------------------------------------------------- -------Owner and/ ontract + (Plot Ian, showingsizeof lot, location of system in relation' -----(Ti+le)_____________________.__;____________..___.___._______.___-- -' f Y ( p g ' y ion to wells, buildings, etc., can be placed on reverse side). r 1 . � ( FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY---..._..- _: -._ V - ._ DATE- REVIEWED BY--------------------- - DATE f�' -------- - - BUILDING PERMIT ISSUED------------------------- -- ------- ------------------------------------------------------------ DATE------------------------------------------------------------- j Alterations and/or recommendations---------------------------------------------------------------------------------------------------------------------------------------------------------------- --------------------------------- ---------------------f--------•---------------------------------------------- ---------------------- -----------•--------•-------------- -- ��n _ ._ -`------ -_-`----------------------------- t --------------- ----------------------------------------- ------ --- -- - --- ------ -------•- ---- --- --------- -- ------------------------------------------------------------------------- --------------------------------------------- FINAL INSPE - ------------ --- --- -- -------- ---- - Date----( ------------ `� ------------------------------ SAN JOAQUIN LOCAL HEALTH DISTRICT 130 5oufh American Street 300 West Oak Street 132 Sycamore Street 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California ES-9-2M . Revised 1.57 F.P,CO. - r