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APPLICATION FOR SANITATION PERMIT Permit No3___?._..f..../.... ` (Complete in Duplicate) t, Date Issued Application is hereby made to the San Joaquin Local Healt District for a permit to construct and install the work herein described. This application is made in compliance with County/] OrdWe No. 5 -----------------------—------------+---------------------------------------------------------------- JOB ADDRESS ANI16 L I N- 7 l - -------- i 1Ll -_--. Phone--�---Owner's Name_ _'__ --- -- ---- ------- - - Address----Ca. ------- ----------- ------ ---------------------------p----_ ------- -------._.� � . Contractor's Name---- ------- --- ------ - ------- --- -------------------------- ---------------.•----------------------- ----- Phone----------------------------------- Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Ot �r [INumber of living units: _�____ umber of bedrooms __ . Number of baths ___ _. Lot size . x�_�________-----------------.------ Water Supply: Public system [ Community system ❑ Private ❑ Depth to Water Table __. ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam P Clay Loam ❑ Clay ❑ Adobe e/Hzirclpan ❑ Previous Application Made: Yes ❑ No V New Construction: Yes &'NNo ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted 'f plic se is available within 200 feet.)► �,' Septic It nk: Distance from nearest Al-wel _'______ __ ista ce fr fou dation__I_ "`"fvlater/ ________' "._..__:______ [, No. of compartments_____-- -- -_--_-- Distance ze _. - --Liquid glepth----- ---h�'------------Capacity---- -f �V r ,- j Dispos 'Field: Distance from nearest we ___ ____ from foundation_L_ _ /r""'Uistance to nearest lot lin _ . ------- - --- ength ne- T Number filter materi - - ��De th off f Iter�mlateri � -_Width of trench._______ �_�_+__.________ Type r p material------ length---------� --Q-- Seepage Pit: Distance to nearest well_____________ ----------------------Distance from foundation-------------------.Distance to nearest lot line----------------- El ______._________ ❑- •,� Number of pits---F�-----------------Lining material---------------__ Size: Diameter------------- --------. Depth-__ ------- ------------------ Cesspool: - ------- - --Cesspool: Distance from nearest well________________Distance from foundation--------------------Lining material------------------------------------- El --- ----❑ Size:°Diameter---I f ------- Depth------------------ --------------------------- Liquid Capacity----------- -------------•--gals. Privy: Distance from nearest well--------------------------------------------------Distance from nearest building--------------------------------------- ❑ Distance to nearest lot line.--------*----------------------------------------------- ----------------- ------I-------------•--------------------------------------- Remodeling and/or repairing{describe)!--------- --------------------�- ---------------------- -------------------------------------------- ------------------------------------ ------------------------------------------------------------------------------------------------------------------•-------------------------------------------------------------------- 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 r Caul tions of the San Joaquin Local Health District. (Signed) ---- ------ ------------------------------------------------------------------{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 B V_-_ --- - DATE. i;l-------------------- BY------•-------------------- ------------------------------------------------------------------------------- DATE_: a-------------------------------------------------- BUILDINGPERMIT ISSUED--------------------------------------••-.--------------------------------------------------------..-. DATE--------V----------------------------------------------- -- Alterationsand/or recommendations------------ ------------=-------------------------•---------------------------------------------------------------------------------------------------------- ------------------------------------------------------------- i ------------------------------------- I ` ----------------------- -- -- ------------------------------------------------------------- FINAL INSPECTION BY:------ ----- --- Date.-------- ------------------------------------------- 1 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 Ix ES-9-2Mio-52 Revised W-2100 c