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APPLICATION FOR SANITATION PERMIT Permit No. (Complete in Duplicate) 111 Date Issued Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described. This application is made in compliance with County OrdinanceIN0. JOB ADDRESS AND LOCATI N---------� - - -- ------ - ---- -------- ----- ------------ Owner's Name---------------- --- Phone ----------------------------- I Address X--- --�+r----- -- ---- hone ¢ e Contractor's Name T Installation will serve: Residence Apartment House Commercial ¢ p ❑ ❑ Trailer Court [I Motel Other E]`. Number of living units: _ ____ N er of bedrooms _ ___ Number of baths I_ Lot size ---W Z - �- --------------------- Water Supply: Public system Community system ❑ Private ❑ Depth to Water Tabl6 Q_ ft. Character of soil to a depth of 3 feet: Sand ravel ❑ Sandy Loam ❑ CJay Loam ❑ Clay ❑ Adobe Ve<clpan ❑ Previous Application Made: Yes ❑:: No New Construction: Yes LCT4o L❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tank: Distance from nearest well-________________Distance from foundation--------------------Material ______________________.-____-_________. ❑ of compartments----- --------------------Size----•---------------------------Liquid depth.-------- --------------Capacity Disposal Field: _ istance from nearest well-----------------Distance from foundation--------------------Distance to nearest lot line----------------- C� ❑� Number of lines-----------------------------------Length of each line------------------------------Width of trench.-------------- 42✓ Type of filter material--------------------- epth of filter material--------------------_.-Total length------------------ -------------------- Seepage Pi Distance to nearest well_#,�d_--_ --Distance om�fo dation,Z,�__________.Distance to nearest41oIine__,_,,6Number of pits__ _ __Lining material Size: Diameter ! ----..____Depth--- Cesspool: Distance from nearest we1L____------------Distance from foundation---.----------------Lining material___--___________.________________._ .�. I :❑ Size: Diameter----------------- -------------------Depth-------------------•--------------------------------Liquid Capacity------------ gals. Privy: Disi-ance from nearest well-------------------------------------------------Distance from nearest building------------------------------ ❑ Distance to nearest lot line------- Remodeling and/or repairing (describe):---------- _ --t ------ - -- --------------•-----------------------•-------•---•-----------•-------------------------------------- -------------------•---------------------------------•--------------------------------------------------------- I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State lcipyncl rules aj regulations oft San Joaquin Local Health District. (Signed) ----- �er Contractor) By: L•�. ... -------------------------------------------(Title) (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY DATE REVIEWED BY ---------------------------------- ------- ---------- ------------- ------------------------------------------------------------------------- DATE--- ' BUILDING PERMIT ISSUED---------------- -------------------------------------------------• ---------- DATE " ------------------ Alterations and/or recommendations:------ W'----- ..._ ---------••---------_--------------------------------------------------------------------------------- ---------------------•------•-------- ------------------------- •------------ -•----------------------------------•---------------------------------------------------------------------------------------------------------------------- ----------------------------- FINAL INSPECTION BY: 047* DateJT b-31 -- 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 f0-52 Revised W-2100