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i APPLICATION FOR SANITATION PERMIT Permit No. .�� _ l____ (Complete in Duplicate) { r 1 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 wity%0 y Ordinance Nq._5�LCJ JOB ADDRESS AND LOCATION--------------------- - ------------------ T - = ---------------- -- ------- ----- - -- Owner's Name . F,--t - --------------- --- Phone 7 3 - -------------------- -- ----------- -------------------------------------------------- Address --- Address-------------------------� � �U ��^'�' .-- �� ._.- Contractor's Name------------------------------- --------- ----------- Phone----------------------------------- Installation will serve: Residence X Apartment House ❑ Commercial E] Trailer Court E] Motel ElOther ❑ Number of living units: -_---__. Number of bedrooms -_Z__ Number of baths ._/--_ Lot size --__--_--- Water Supply: Public system )A Community system [] Private ❑ Depth to Water Table -------- ft. Character of sail to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe O Hardpan ❑ .t Previous Application Made: Yes ❑ No K New Construction: Yes X No ❑ 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--P?'�Distance from foundation___--/D--.____.Material--__ ------------------------- -------------- No. of compartments---- -------------- SizeX.S ---Liquid depth-------- -----Capacity------- --Q-Q----- Disps �. r Field: Distance from nearest weEl-_1 Distance from foundation-------/a--_--Distance to nearest lot line.-_�_O-C) Number of lines---- -- Z.Qr----Length of each line------------------------------Width of french-----------2�eg_I/___--_-- Type of filter material---I_ _-_Depth of filter material--.---� ��______-Total length--------------� f2-_�.____--__---- s _ Seepage Pit: Distance to nearest well----------------------Distance from foundation-_.---------------Distance to nearest lot line---___--------__ ❑ Number of pits----------------------Lining material-----------------------Size: Diameter-----------------------Depth--------------------------------- Cesspool: ----------------------_---- -Cesspool: Distance from nearest well-----------------Distance from foundation------------------- Lining material--____- _-_____--_____-------- ❑E _-. Size. Diameter---------------------- ---------------Depth--------------- ------------------------- ----------Liquid Capacity----------------------------gabs. Privy: Distance from nearest yell-------------------------------------------------Distance from nearest buildin ❑ Distance to nearest lot line -- ---__-- g - Remodeling and/or repairing (describe):-----.--I. r ` r ------------- -- -• -- --------------- -- ------------------------- ----------- ------------- ------ - - ---•---� ----- ------------------ ------------------------------------------------------------------ ----- --- - ----------------- -----------------------------•Z---------------------------------------------•---------------- 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 rules andregulat' ns of the San Joaquin Local Health District. (Signed)- = /'.--:` (Owner and/or Contractor) By:-----------_------- -----------------------••------- ----- `------------------------- ---------------------------------------(Title - ---- -- ------ -------------------- - ---- - Pat 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-------- ------------------ - - ----- ---- --- REVIEWED BY---------------- --------------- ---- DATE < ' ----------------------- DIN PERMIT ISSUED------------------------------------------------------------- -------------------------------------- DATE -------------------------- ------------------------------------------ Alterations and/or recommendations ------------------ __ -----------------------------------------------------------------------------------------•----------------•-------------------------------- ---------------------- --------- - FINAL INSPECTION BY: � --------------------------- Date.-.--// SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 304 West Oak Street 132 Sycamore Street 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California ES-9-2M 8-51 Revised W-2100