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APPLICATION FOR SANITATION PERMIT Permit No. __ � -- (Complete in',,Duplicafe) Date Issued y.F Application is hereby made to the San Joaquin L`ocal+Health•District four e/Permit o construct and instal{the work herein described. This'applicatiori is made in compliance with County Ordinance.,No. I N--- - _'-`�=------- ---------------- -------'-----�--�---------_---�:---t- --------- -------------------- -------- JOB ADDRESS AND LO i------ ------------- Pho ne------------------------------------ ---- -•----Owners ame- - ---- ----------- ------------------------------------ --------------- ------ ------------------ ------•--- Address--- Phone----------------------------------- --------• ----- ---------- %Contractor's Name Installation will serve: Residence [ Apartment House ❑ Comme Bial: ❑ Trailer Court F]4 Motel ❑ Other E] j` uu�� , Lot size��{ Q -� Number of livingtun�t`s; ..F= Number of bedrooms _.p+Sr�Numberof baths . ri Water.Supply: Public system Community system ❑ Private ❑ + Depth to Water Tableft. i. x Character of soil to a depth of 3 feet: Sand ❑ Gravel El Sandy Loam E] Clay Loam El Clay�� !Adobe Hardpan C] Previous Application Made:' Yes No F1 'New Construction: Yes ❑ No l ray'/VA: Yes ❑ No s TYPE OF INSTALLATION AND SPECIFICATIONS: j ' �- i (No septic tank or'cesspool permitted if public sewer is available within 200 feet.) II pticInk: Distance from nearest well-----------------Distance from_foundation--------------------Material....-.-_-.-.---...___.._-..._..---.----------. No. of compartments.... -- ------Size--------------------`------------Liquid depth--------------------------Capacity----------------------- D o1sal Id: Distance from nearest well---------. Distance from foundation....................Distance to nearest lot line...__:...-...: IINumber of lines----------------- -----------------Length of each line------------------------------Width of trench------=-------------i------------- Type of filter materiai------'----------------Depth of filter material--..-----------nn---�Total length------------------------------ pC�_ .._,Dist nce to nearest to line_.-- -__-- Seep'age it: Distance to nearest well_;'...:' - _.--Distance from ndation___.. . Dept -- --------- Number of pitsW11 - __...- Lining material_ _!-___Size: Diameter__ /f p Cesspool: Distance from nearest well-----------------Distance from foundation------------------- material---------------------------- -- -- als. ❑ Size: Diameter- ------------------------ ----------Depth------------ 0--`--:--------------------------------Liquid Capacity- --------- g Privy: Distance from nearest well ....................................'...----...Distance from nearest building...___--------_...___.._..------__..- ❑ ----------- -----------------•------------=------------------------- -------- ------------------------- Distance to nearest lot line_-- ..... , _... -.. ...............V._...---._..._--- ' Remodeling and/or re i �' scribe):--------- -- ------- ---•------------------------------ ----------------------•------- - -- 1 ----------------------------------------------- -----------------------------------------------------I----- -------- ----- - ------ --------------------- ---------------------------------------------------------------------------------------------------------------------------------------------- I hereby.certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State laws, and rulpl and regulatio of the Sa Joaquin Local alth Distript. f� _... -------(G1nVW0ft4kt Contractor) (Signed). .g ---------- _ ------ --------- ��A (Title)------- ---- --- -----` ' (Plot plan, showing size of lot, location of syste relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY r APPLICATION ACCEPTED BY------------- --- --- ----------------------------------------------- -------- ------------------------------- DATE REVIEWED BY-------------------------------------------- - ' ------ -- -- -- --- - -- --- -------- ------- - QATE- r ------ -- ------ - --------------- BUILDING PERMIT ISSUED------------------'------ ------ ----------------------------- DATE------------------------------------------------------------- Alte/rn�at'' r recomme tions- --------------- --------- ---- 1 / i .._-._ __ --Y..__.. ....-/ -�--� _ l ----------------- SS FINAL INSPECTION BY:. ---- Date--- '^ ----- ---------------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT Z 130 South American Street 300 West Oak°Streeti 11 132 Sy amore Street �w� 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, Californ- ia � 1 ES-9-21M Revisea 1-57 F.P.CO.