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APPLICATION FOR SANITATION PERMIT Permit No. ------------- (Complete ______ ___(Complete in Duplicate) Date Issued Applica4-ion is hereby made to the San Joaquin Local Health District for a permit to constru and install the wor herein described. This application is made in compliance w' County Ordoance49. JOBADDRESS AND LO AT ON..:.. _._ -- --------------------- ------------------- -----�-....... = - ------------ --------- Owner's Name .f7 _ h_C7e/ ------------ Phone Address------------------------------------- --------- --- ` - 1� Contractor's Name •-- --- -------------------------------------------------- Phone----------------------------------- Installation will serve: Residence [Apartment House ❑ Commercial ❑ Trailer Court ❑ Mote E] Other E]_ Number of living units: ___(._ Number of bedrooms __ Number of baths -------- Lot size __�_ 's-.._ --------- ---------•-- Water Supply: Public system ❑ Community system ❑ Private �epth to Water Table -------- ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe[ ardpan ❑ Previous Application Made: Yes ❑ No ❑ New Construction: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if publisewer is available within 200 fee ) Septic T Distance from nearesr well_ ------------Distance from foundation__ /____Material___ ____ cr e No. of corripartments___� ___.__. ---_Size_t _" �! Liquid depth_ _____________Ca acct _ -19-.-� P Y ---------------- Disposal Field: Distance.from nearest well_ d Distance t3om foundation__6,.-_M__.Distance to nearest lot line_______. Number of lines_--------- Length of each line----�2__D--------------Width of french---- -5�-��--------------- , T t --- Type or filter material____._.. j --- --Depth-of filter material----/:?-��___._._Total length__° _'�^ _r______________________ 1. Seepage Pit: Distance to nearest well----------------------Distance from foundation--------------------Distance to nearest lot line----------------- \ ❑ Number of pits-- ---.----------------Lining material-----------------------S:ze: Diameter_- -------•-----------Depth-------------------------------- - \� Cesspool: Distance from nearest well----------------Distance from.foundation---------------------Lining material--------.-_-____-_____________.______ (� ❑ Size: Diameter-- '----------------------------------Depth----------------------------- r-----------._Liquid Capacity----------------------------gals. Privy: Distance from nearest well---------------------_—_--------------------------Distance from nearesf building____--------_---_----__•-_-_.----_-___. El Distance to nearest lot line--: +--------•----------------•----- ----------------------------------- t Remodeling and/or repairing (describe):-------._------------------------------- i ` ---------------- --------------------------------------------------------------r-------- a --------------------------•--------------.--...-------------" ----•---•--------•-•-•-----------------------------•----`----------- .--------------------------------------------------------------------•------------ j _______________________________________________ I ordinances. State laws, n rules an -ui y n -- 1 ' I hereby certify +h have prepared this application and that the work will be done in accordance with San Joaquin County ' regulati s of the San Joaquin Local Health District. (Signed) -------------------- --------------- - - --- BY=----------------------------------------- {Ti+le) rti 1•.rt�! (Plo+'plan, showing size of lot, location of system in relatio to wells, buildin , etc., can be placed on reverse side). l FOR DEPARTMENT USE ONLY ------ ------ -------------------------------------------•----------------------- DATE. REVIEWED BY--ACCEPTED BY-------�------------------------------------------------------------------------- DATE ---- -_..-------•----------------•--------------- BUILDING PERMIT ISSUED - DATE------... Alterations and/or recommendations=--------------------------------------------•-•--------------------------------------------------•------- ... -- -------------------------------•----------------------------- ----------------------------------- --------------------------=`�'� "-�� -,1 � ------ ---- �� _� - k- -----•----•.-•---------------------- ---- ! _ - -- r --------------------------------------- _ . _ __- ------ 9FINAL INSPECTION BY--------------- ------------------------- ------ Date---i------ --` I� r k J . SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street i 300 West Oak Street 132 Sycamore Street 814 North "C" Street i± Stockton, California Lodi, California Manteca, California Tracy, California $ ES-9-2M ; ' Revised W-2100