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APPLICATION FOR SANITATION PERMIT Permit No. (Complete in Duplicate) Date Issued --- Aplica-lion 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. JOB ADDRESS AND LOCATION -------- -------------- L Owner's Name-- ----- - ------- -------- - - ------- --- --------------------------------- Phone --------------------------------- ----------------------------------------------------------------- ----- Address--. ---- ---- ---- � Contractor's Name------------- - -- --------------------------------------------------- ------ Phone-_----- 7-/ Installation will serve: Residence Apartment Ouse [:1 Commercial 0 Trailer Court ElMotel ❑ Other E] Number of living units: Number of bedrooms - Number of baths ---/___ 'Lot size ------- Water Supply: Public'system Community system E] Private [] Depth to Water Table /_A6_9'ft, Character of soil to a depth of 3 feet: Sand E] Gravel [] Sancly,Loam E] Clay Loam El Clayd Adobe_)W Hardpan Ej Previous Application Made: Yes E] I N O>4-' New Construction: Ye�No El TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool pe'rmitted if public sewer is available within' 200 feet.) Septic T k. Distance s+t;n-ce fro'm nearest well-----------------Distance from foundation-------------------Material--- ------------------------------- --- ---------- -No..of compartments---j------------------.-.--Size--------------------------------Liquid depth---------- --------------Capacity----------------------- Disposal ----Capacity----------------------- Disposall •i 0 Distance from nearest well-------_--------.Distance from foundation--------------------Distance to nearest lot line_---__-----__-_-- . Number of lines-----------------------------------Length of each line------------------------------Width of french Type of filter material-------------------------Depth of filter material-------_--- Total 1e'ngfh----------------------------------------- ;Se e I I I IF ,p all e Distance to nearest well-- - __----------Distance ff rn ff ndation- Distance to nearest lot ]in e-------4--------- N umber of pits-- A --- ------------Lining material- A, Size: Diameter----.,, Depth........ es'pool Distance from nearest well-------- Distance from foundation-----------_------.Lining material-----.----------------_-------_- Lfi ❑ aterial----- -------------------------------- 171 Size: Diameter-------------------------------------Depth-----------------------------------------------{----Liquid Capacity----------------------------gals. Privy: Distance from nearest well---------------------------------------------- - g-------------------------------- i _-Distance from nearest buifdin F❑ Distance to nearest lot line:------- - - - - ------------------ ---------- . + Remodelin ine--------- Remodelin repairing (describe):------ �------- -- ---- -- --- - il _rlle------- --- --- ------------ ...... -------------------------------------- ----- ---- ------------------- ---------------------------------------------------------------------------------------------------------------- -- ---- --------------------------------------------------I------------------------11------------------------------------------I------------------_--------------------- ----------- ---- --- ----------------------------------------------------- ---------------------------------7-------------------------11----------------------I ------------------------------- ---------------- I hereby certify that I have prepared this application and that the work will-be-done-in accordance with San Joaquin County ordinances, St aws,1 d ules an gulaflons of the San Joaquin Local Health District. (Signed)------------ ------------------------------------------------------------------------------- ------------------- (OwnF a�n 0 , /or Contractor) (Plot plan. showing size P_ --------------- rs, si By:----------------_.7- __Ip_ - __:-----I f ---------------------------------------------- -------------------------------------(Title lo locatio'n of system in relation to wells, buildings, etc., can be �Oc d&.n rev rse e). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY-- 0x_ REVIEWED BY------------- ----------------- DATE ------------------------------------------------- ----------------------------------------------------------- -------------- DAT ----- VNI- --•----------------------------•------- BUILDING PERMIT ISSUED------------------ ------- ------------------------------- DAT ------------r ------------------------ Alterations and/or recommendations:-------------- I ------------------------------------:------------- -----------------I-------------------------------I---------- ------ *----------------------------------------------------------------------- --------- ---------------------------------------------------11------------- ...... --------------------------------------- i --------------------------------------------------------------------------------------------------------------- I ---------------------------------------------------------- -----------------------:--------------------------------------------------- -----------------------------------------------------------------------------------------------------*----------*--------------------- ------------------------------------- ------------------------ -------------------------------- --------------------------------------------------------------------------------------- ------------------------------------ BY:-- -1 ------ - FINAL INSPECTION ISAN 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 Revised W-2100