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APPLICATION FOR SANITATION PERMIT Permit Nor-1?47-7-Z--/ (Complete in Duplicate) Date Issued _ - vs--?-- 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 with Co, jnty rdinance No. 5 . JOB ADDRESS D LOCATI N.____._ __-- ------------------- --------------- Phone ------------- d ------- Owner s N me----- .--- . t-- Address---- --�------ --t. ----------------------•-----•---------------- -------•-------------------------------------- Contractor's Name___ Phone----------------------------------- Installation will serve: Residence Rj Apartment.House ❑ Commercial ❑ Trailer Court ❑ Motell ❑ Othyr ❑ �1g �I -------------------------•- Number of living units: _-� _ umber of bedrooms ___/___ Number of baths -_l�____ Lot size ______ __ .- Water Supply: Public system w Community system '❑ Private ❑ Depth to Water Table -------- ft. ` Character of soil to a depth of 3 feet: Sand Gravel ❑ Sandy Loam 0- Clay Loam ❑ Clay E] Adobe[,Hardpan ❑ Previous Application Made: Yes ❑ No New Construction: Yes M"*4No ❑ O t TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted, pu6lic sewer is available within 200 feet) j 6c? fro fou tion___f11._ ---.Mater•al______ ��--Septic Tank: Distance from nearest well _ 4 ista ,�` __,_Ca ac-- Y Size; + -'"~=----Liquid dept-------- ,--- P Y-• y No. of compartments-----,- _ ___ � -_ T ' Distance from foundation___.----Distance to nearest lot in ---------- A __ 4 Dispo A Field: Distance from nearest well'Nf_ - _. � �' Number of lines-_______-__ �_ - 1 Length of each line_________________ Width of trench___.___! _ ----------- Type of filter materi�- s - epth of filter material_____ _ ---------Total length_--_____-_ �------------------- Seepage Pit: Distance to nearest well___________________--Distance from foundation____.______-___.___.Distance to nearest lot line_______-________ Number of pits---------------------Lining material-----------------------Size: Diameter------------------------Depth--------------------------------- Cess❑pool: 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)______________________________________ ------------------------------------------------------- -_------------------- -------------------------------------- ---------------------- I hereby certify th�-faprepa'e rthis egulations application the San Joaquin the Localwork -will be done in accordance with San Joaquin County y Y ordinances, ;Sf4atela , apd rules4xig Health District. (Owner a Contract _. ". [Ow and/or ori (Signed) lam'--------rbi----- Title BY- ------------- (Title) (Plot plan, showing 'ze 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_ - ---------------'------ DATE-------- BUILDING PERMIT ISSUED----------- DATE------------- Alterations and/or recommendations__________________________________________________ ----------------------------------------••------------- •-------------------------------•-------------•---------•-----........ -------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ ----------- ---------------------------------- FINAL INSPECTION BY:-------i - ---- ----------------------- ----------- Date--------�_.�_-�_�--�-----------------------------•------------------• SAN JOAQUIN LOCAL HEALTH DISTRICT 300 Wes+ Oak Street 132 Sycamore Street 814 North "C" Street 130 South American Street TracCalifornia Stockton, California Lodi, California Manteca, California y� ES-9-2M 8-51 Revised W-2100