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1/ APPLICATION FOR SANITATION PERMIT Permit No. (Complete in Duplicate) 4D Date Issued Application is hereby made to the San Joaquin Local Health Dis+rict for a permit to construct and install the work herein described. This application is made in compliance with County Ordinance o. 5 JOB ADDRESS AN OCATION... ------- Owner's Name-------- - ------• --- - --------------------------------------------------------------------- Phone--- ----- Add' -- Address Contractor's Name - -- - - ----------------------------------------------------------------------------------- Phone------?--- Installation will serve: Residence Apartment House ❑ Commercial (] Trailer Court El Motel E] Other ❑ Number of living units: Number of bedrooms__ Number of baths• Lot size w: Water Supply: Public systemn,,KCommunity system '❑ Private ❑ Depth to Water Tabiee..5r ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑. Clay ❑ Adobo-k Hardpan ❑ Previous Application Made: Yes 0 No)K"' New Construction: Yes ❑ 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_________________Distance from foundation______________-.__.Material No. of compartments--------------------------Size-------------_-------- ---------Liquid depth_----------------_-__-_ -_-._C_--a_-_p-_a_-ti+ Yx7% d Disposal Field �) Distance from nearest well__________________Distance from foundation to nearest lot line----------------- l / 7/ Number of lines-----------------------------------Length of each line-------------------------------Width of trench----------------------------------- 4� Type of filter material_________________________Depth of filter materiai_____-------____ Total length ------------------- See age Pit: Distance to nearest wet ( -_--_---Distance f m fo dation____e-_________-Disfance to nearest lot Number of pits -/----------------Lining material- Size: Diameter. - ------.Depth____/�- ------------� Cesspool: Distance from nearest well-----------------Distance from foundation-------------------_Lining material------------------------------- p --------------------------------Liquid Capacity----------------------------gals. �Y • Size: Diameter--------=�--------------- - -------De Depth-------------- -- - Privy: Distance from nearest'well----------------------------------_--------------Distance from nearest building------------------------------------------ F1 Distance to nearest lo+ line- --- ---------- Remodeling and/or repairing (describe) ;/ " ......... --;----_--------- ------------------,----------------..-------------------------•------------- -------------------- ------------------------------------------------ ------------------------------------•---------------------------------------------- -------------•-------• ----------------------•---••-----------------------------------•-,J ----------------------------•-------------------------------------------•-----------------•------------------------------- ------------------------------------------------------------• ---------------------------------- 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 a d rules r ulations of the San Joaquin Local Health District. (Signed). ---� ---- (owner and/o Co attar) BY•----------------------------------------- ---,----�- -'--------------------- - --•-------------------------------(Title}j---��--,.��--�=--:'-=Thr-"'---�,;.•�---- - __. . (Plot plan, showing size of lot, lot ion of system in relation to wefts, buildings, etc., can be p aced on reverse side: y } FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY ------ - _ - ------------------------- DATE REVIEWEDBY - -------------------- ---------- -------------------- ------- ----------------------------- DATE BUILDING PERMIT ISSUED-------------- ------------ DATE-- ------ --- -------------------------------------------------------------- -----=----- ' I Erasy+.e A ✓ =Alterations and/or recommendations:---_ � � � ---------- l ►.a � 41, - ------ -------------- -- _ ---------------------- -- ------------------------------------ ------------------------------- -- FINAL INSPECTIONBY--- - ----------------- --- --------- Date----=-- ----------- - ------------•------------- ----------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American S+reef 300 West Oak Street 132 Sycamore Street 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California 1=S-9-2M 5-51 Revised W-2100