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APPLICATION FOR SANITATION PERMIT Permit NoZ:-_6-4_--------___ .2z- 0- -5, (Complete in Duplicate) Date ]sued Application is hereby made to the San Joaquin Local Health District dor a permit to construct and install the work herein described. This application is made in compliance with County Rdinance No. 5 JOB ADDRESS A D LOCATION-- '°� --- ---------------------- ! f` '---------------------------------------------------------------------------------------------- Owner's Na ------------------------ Address---------- --- -- --- - ------t`u --- -------------- ---- -------------- ------------------------------------------------------------------------------------ Contractor's Name---- -r-- -------------- -------- Phone----------------------------------- Installation will serve: Residence Apartment. House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: A-_-- Number of bedrooms ----III--- Number of baths ---/--- Lot size _- -0--_KIZ_ ----------------------- Water Supply: Public system [vCommunity system ❑ Private ❑ Depth to Water Table -------- ft. Character of soil to a depth of 3 feet: Sand [j Gravel [] Sandy Loam ' Clay Loam ❑ Clay E] Adobe 9--/Hardpan ❑ Previous Application Made: Yes El No R( New Construction: Yes Vo ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank cesspool permittedu is se r is available within 200 feet.) r Dlstance from nearest well _ D Matera---j------------------ ------------- -t--------_-_----.Septic Takffi _---- -- -____-. u yizeNo- of compartments � Liquid deph-- -_--.-CaPa 13 :Dispos Field: Distance from nearest we - _- - e from foundation-: -- - f--_- Distance to nearest lot line-,- [v Number of lines----------- --- -- - _. Length of each line------------ --It--.Width of trench___- Type of filter materia _-- ypDepth of filter material--------- - -------Total length-------- Seepage Pit: Distance to nearest well----------------------Distance from foundation____________._.____.Distance to nearest lot line------------------ 11 Number of pits----------------------Lining material=-----_-- -----____--.Size: Diameter------------------------Depth-------------------------__------ Cesspool: Distance from nearest well-----------------Distance from foundation-----------.-------.Lining material____---------------_-----__.----_____. ❑ Size: Diameter------- ------------------------------Depth---------------------------------------------------_Liquid Capacity----------------------------gals. Privy: Distance from nearest well--------------------------------------------_----Distance from nearest building----------------------------------:----_-. ❑ Distance to nearest lot line----------------------------------------------•--------•-------------------------------------------------------------•----------------------- Remodeling and/or repairing (describe):------------------------------- --------------------------------•--------------•--------------------------------------------------------- --- --------------------------••------------------------------------------------------------------------------------------------------------•-----------••-----------------------------------•-__------.------------------------- -7------------------------------------------------------- ------------------•-----------------------------•---------------------------------------•---•---------------------------------------------•------------------ --•--------------•------------------------------------••----•--------------- ----------------------------------------- ----------•-----------•-•------------•---------------------- --------------------------•-------------•----------•------------------------------------------------------------ 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 and regulations of the San Joaquin Local Health District. (Signed) 4 ---___-- -- Owner and/or Contractor BY------------------------------------------'------------------------------------------------------------------------------------------(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__--______ - REVIEWEDBY---------------------------- - -- -------------------------------------------------------------------------------- DATE------------------•----- BUILDING PERMIT ISSUED------------------------------------- _ = --=----------•-------------------------------•------- DATE------V------------------------- Alterations and/or recommendations ---------------------------------------------- ----- - ---------------------------------------w-------------------------------- ----------------------------------------------------------------------------------------------------------------------------------------------- - ---------------------------------------------------------------------------------------------------------- ----------------------------------------------------------------------------------------------------------------------=•----------------------------------------------------------------------------•-------------------------- - -•------------------------------------------------------- -------------------------------------- •---- -------------------- 4� s FINAL INSPECTION BY---------------r. ------------------------------- Date----------- -------'r---- ---!!7� 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 8-51 Revised W-2100