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APPLICATION FOR SANITATION PERMIT Permit No. ________________________ (Complete in Duplicate) Date Issued Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described. 4 This application is made in compliance with County Ord inan c ...o_5,d 9--.— JOB ADDRESS AND . _ � --------- Owner's ----- Owner's Name-------�� /� ---- �,,_ ,_ -------------- ---------------- -----------------/---�-- �--r--�------------ _Phone--_------------------- t ----------------------------------------------------•-------------------------------- Contractor's Name.............~ -- Phone----------------------------------- Installation will serve: Residence DQ Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: -A___ Number of bedrooms -4,-- Number of baths ---T_ Lot size ---�X_A__r1'6______________________________ Water Supply: Public system ❑ Community system '❑ Private Z Depth to Water Table it. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam JZ11 Clay Loam ❑ Clay ❑ Adobe ❑ Hardpan ❑ Previous Application Made: Yes ❑ No New Construction: Yes No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS:- (No septic tank or cesspool permitted if public sewer is available within 200 feet.) A —/- j Septic Tank: Distance from nearest well- _�______Distance from fouundation--_�,5__.___-_Material- '` --------- ------ Septic -h ----Liquid depth--------�---- Capacity 4 ® No. of compartments___--------- -'° f Disposal Field: Distance from nearest well--- _ --------Distance from,foundatio __ _______Distance to nearest lot line_____--- Number of lines---------------- --Length of each line------- -- ------------.Width of trench-------,! -------------------_--- ------------- Type of filter material___ __ _I _____.__Depth of filter material_____�_ ___.___ ----Total length__________:_C_ __________-.__ji - -------------- Privy: Seepage Pit: Distance to -Kearest well----------------------Distance from foundation-------------------- to nearest lot line---___________ Number of its--------- Lining material-----------------------Size: Diameter------------------------Depth_-----------------------------J� e'o.�l: Distance frarrm nearest well-----------------Distance from foundation _______________.___.Lining material____________________________'__-_ ❑ Size: Diameter------------------ ------ - ------Depth----------------------- -----------Liquid Capacity---------------------- ----ga Distance from nearest well_________________________________________________Distance from nearest building___-:___________-- -________ ❑ Distance to nearest lot line_______._.____________- --------------------------------------------------------------------------------------------------- - Remodelingand/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, Stat laws, and ules and regulations of the S n Joaquin Local Health District. Signed ��F (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__________ ___ ____ ,fid, DATE --- ---------------------- REVIEWEDBY----------------------------------- -- - ------------'----------------------- DATE---- -------""- ` dr BUILDING PERMIT ISSUED---------- ------------------------------------------------------------------------------------------ DATE-------------------- - , Alterations and/or recommendations--------------------- ----------------- ---------- �✓ ------------------------ •------------ - - -------• ------------•---------------------------------------------------------------------------------------------------- ------------------------------ ------------------------------------------------------------------------------------------------------------- FINAL INSPECTION BY------------------ r Date SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Street CNorthStockton, California Lodi, California Manteca, California ES--9-2M 8-51 Revised W-2100