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APPLICATION FOR SANITATION PERMIT Permit No. .-S 9 Complete in Duplicate) // � Date Issued ___�, rs~ Applica}ion is hereby made to the San Joaquin Local Healfih District for a permit tg, true and install the work herein described. This application is made in compliance with County Ordinance g.., N4q, U _{ JOB ADDRESS AND LOCATION} :_-'_s ..G4 _, �-_ _._ -- ,,,, Owner's Name___ ---- - Address Phone r---- Contractor's„Name________ � ---------_------------- .......... - __. _, ""``------------------------------------------------------ ------------°- -----------------------------•------------------ Phone----•--•-•--•- -- Installation will serve: Residence ® Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other Number of living units: Number of bedrooms _.�,_. Number of baths _� ❑ ----- Lot size ---•-^�-----�-7-�' °�--------------------. Wafer Supply: Public:system ,❑ communitysystem ---- Y ❑ Private ® Depth to Water Table _�+_�_ ft. - Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe® Hardpan Previous Application Made: Yes No p ❑ ❑ ® New Construction; Yes ® No [] TYPE OF INSTALLATION AND SPECIFICATIONS: '�,... (No septic fank.or cesspool permitted if public sewer is available within 200 feet.) Septic Tank. Distance from nearest welL__FO_FrDisfance from oundation__3-A- �p F _.Material-___4a_ _ ® No. of com artments_--____ _ i ---.-____- p --etc•-------- Size_3_� �--- --.��.Liquid depth-------�--�r---- Capacity ---- isposal Field: Distance from nearest well Liquid rDisfance from foundation___-26—PT.Distance to nearest lot line___ T Number of lines-------IZ__-- ------ .Length of each line--------- .__ r.-..Width of french.- Type of filter materiaLQ. - ---Depth of filter material-_ ° --Sl`_.vr ' ofal length 'P-, t - T. Seepage Pit: Distance to nearest well_ ________Distance from foundation---------------------Distance to nearest lot line________________ ❑ Number of Pits---------------------Lining material__ _ Size: Diameter-----------------------Depfh------------------------- --- -------- Cesspool: Distance from nearest well _____________Distance from foundation-----,--------------Lining material-------------------_-________ ❑- Size: Diameter- ---- ,.Depth.- .:_ _ Liquid Capacity gals. Privy: Distance from nearest well-------------------------------------------------Distance from ......... es building -- _ — �~ ❑ Distance to nearest lot line------------ g -1 ------------------------------ -------------------------- -- Remo�eling 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, Stafe laws, and rules and regulations of the San Joaquin focal Health District. (Signed) By: - ---- -(Owner and/or Contractor) ------------------------------------------- ----------- -_ _ = ------------ --- ___;__�_ (Piot 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____ �_�- ---- - _ REVIEWED BY - ----------------------- DATE--- S 17 ----- DATE ---------------•--_------------I_------------ BUILDING PERMIT ISSRIED------------------ .............................................. --------- --------- ---- --------------- ---------------- --------------- ---------- - -- ---------..................................... -- .---------- ------. DATE--------------------- Alterations and/or recommendations:.... _________ __ -----•---- ---------------------------•---------•---- --- ------------------- -------- FINAL INSPECTION B :-- - ---- ----- --- Date---____- r - ------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Street 614 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California ES-4-2M � ' Revised W-2100