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9 APPLICATION FOR SANITATION PERMIT Permit No. (Complete in Duplicate) Date Issued ___ ��_r 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 County Ordinance N�9. I �j Ipc,JOB ADDRESS AND LOCATION-- J �` ! -------- ------------ ---------------------- Owner's Name -- ---•------ Phon -. --- .. .i Address--- d` - ----- --- Contractor's Name. ---------------------------------------- ------ Phone.------•-----. ------------------- Installation will serve: ResideApartment House Commercial Trailer Court Motel Other nt V E] E] E]Number of living units: __1.... Number of bedrooms .-A- Number of baths ---1.. Lot size ...____(2. ----X.1 ---O______________________ Water Supply: Public system ❑ Community system XPrivate ❑ Depth to Water Table lb ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy LoamE] Clay Loam ❑ Clay K Adobe[-] Hardpan ❑ Previous Application Made: Yes E] No K New Construction: Yes Ex No ❑ FHA/VA: Yes ❑ NoX TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or'cesspool permitted if public sewer is available within 200 feet.) , Septic Tank: Distance from nearest wellAAj_4Distarfrom foun�n-------f!__P.......Mate is}__-_�r�d� ---___"-. No. of compartments-_-___Y ___--____Size__ ' X. _ ___�.___Liquid depth------- _J��/__Capacity.... t2__ ?__. `IS Disposal Field: Distance from nea st well �,0.i7_+Distance from foundati n----I -_-_. istance to nearest lot Number of lines _____ :_____ Length of each line___W. ,� .�idth of trench .._ _ __ -•-------- A ti ------- Type of filter material___,. "% Depth of filter material.__7_8---- length----- b.__.________-ffi ______.. Seepage Pit: Distance to nearest well----------------------Distance from foundation....................Distance to nearest lot line____"___-___-___- ❑ Number of pits______________________Lining material--..__________________.Size: Diameter-----------------------Depth__-________________-_-___________ Cesspool: Distance from nearest well-----.-----------Distance from foundation--------------------Lining material----------------------------------.__. [, ❑ Size: Diameter-------------------------:------------Depth-----------•----------------------------------------Liquid Capacity----------------------------gals. V Privy: Distance from nearest well-------------------------------------------------Distance from nearest building-__________________-__•_______________--_. ❑ Distance to nearest lot line----------------------------------------------------------------------------------•----------------------------------------------------------- Remodeling and/or repairing (describe):_____ y�,,,��lrle, __. �E� _7-p �• -------------------------------------------- ------------------------------------------ _------------------------- ---- -- - ------ ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------_------------------ ------------------------------------ ------------ - - - ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ 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 and rules and regulations of the San Joaquin Local Health District. (Signed)-!_ -----Va-----------------------------------------------------------------------------------------------------------(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----___--- REVIEWED BY---------------------------------- ---- - DATE•----- ---- BUILDING PERMIT ISSUED----- ---- DATE--------------------- --- - ------------------------ - - --- Alterations and/or recommendations: ----------------------------------------------"-----------"----"--"----------------------------------•-••-•------------------ ---------------------------•-------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- •------------------------------------------------------•-------------------------------------------------------------------------------------------------------------------------------------------------------------------- -------------------------------------•--------------------------------------------------------------.................................................----------------------------------------------------------------------- ------------ ---------------------------------------- ---------- - -------------------------------------- ------ --- ---------------------------------------------------------- 5-7 -------- --------------------------- -- ------ ------------------- - -- F � FINAL INSPECTION BY----------------- - ------------------------------------ Date-------- -------- - SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Street 014 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California ES-9-2M Revises 1.57 F.P.CO.