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APPLICATION FOR SANITATION PERMIT Permit No.,-s-7----�--- (Complete in Duplicate) Date Issued Applica*ion 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 Ordinance No. S4 9. ----_ -- ------- &-t JOB ADDRESS D LOCATION Owner's Name.-------•------------------- -- ------ Pho ------ ------ --------- Contractor's Name Phone -•----•-- Installation will serve: Residence [ Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Othej ❑ Number of living units: -Xmmunity mber of bedrooms -�-_ Number of baths -/----- Lot size ---:-�_r�- Water Supply: Public system system ❑ Private ❑ Depth to Water Table -------- ft. Character of soil to a depth of feet: Sand E] Gravel [_1Sandy Loam E) Clay Loam [IClay [IAdobe ff"'Hardpan E] Previous Application Made: Ye*, V No ❑ 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-------------- - ---------Capacity..--------------------- Disposal Field: Distance from nearest well-----------_----Distance from foundation--------------------Distance to nearest lot line----------------- ❑ Number of lines------------- ---------------------Length of each line-------•----------------------Width of trench----------------------------------- Type of filter material-----------------------_Depth of filter material -------.--------------Total length---------------- ------ Seepage Pit: Distance to nearest well-_----- ----------_-Distance from foundation-----_-----.------Distance to nearest lot line------_--------- ` ❑ Number of pits----------------- •--Lining terial---------------- ----Size: Diamgter-----------------------Dept = --- - i-------- Cessp Distance from n res elhW_�__Distance from jpyndationjlo----------- Lining material - -- --.-_--- -- ----------------. f !4 ---------------------------Li Liquid Capacity —__0_ /------gals. Size: Diameter-T-�o7-_-Xea -----------Depth q p Y V Privy: Distance from nearest well-------------------------------------------------Distance from nearest building-----_----------------------------------. ❑ Distance to nearest lot line-------------------------- -------------------------------------------------------------- Re odeli and/or repairin (describe)- ------ ------ ------- �ct, -- ---- .�, -- --------------- ------------ ------, ---- ---- V--k - ------- --- ----------------------------- --------------------------- - -------------------------------------• -----------•----------------------------------------------------------------------------------------------•------------------------ I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, ate laws, and rules d re ations of the an Joaquin Local Health District. (Signed) 4 ---------------------------------------------(Owner and/or Contractor) -- - - --------------- 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-s' ------------------ ---------------------- REVIEWED BY.-- -- DATE-__l-1, ---- -- -------------------------- ---- - - BUILDING PERMIT ISSUED------- ----- ----- --- -- ---------------------------- DATE------ ......- -----------------•----------- Alterations and/or recommendations:-------------------------- --------------- --------------------------------------------------------------------------------_ -----------------•--------•--------------------•------------------------- ----------------- ------------------------- ------------------------------------- -------- ------------------------------•-- ------`-----------------------------•---- C FINAL INSPECTION BY-- -------------- -- 1�7.C\�SjYz -------- Date--------�--�--- �--`�-`-I--------•--------------------•------------------- --------------------------------- 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--4-2M ; Revised W-2100