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APPLICATION FOR SANITATION PERMIT Permit N�_ ----1�- -- (Complete in Duplicate) __'-��`' Date Issued _ --------- __ A lication is herebymade to the San Joaquin Local Health District for a permit to construct and install the work/�ein described. This application is made in compliance wit,�C unty Or inance N . JOB ADDRESSA�D LOC 'fiION___.._ .. :- . � , Owner's Na a •- --r ----------------------------------------- --- ---- Phone -- --------------- �a9 Address----- I - ---- 1 - ---------------------------------------------------•-- Contractor's Name--------- --------_: ---- Phone ._ ---------- Installation will serve: Residence ❑ Apartment House ❑ Commercial 4 Trailer Court ❑ Motel ❑ Other ❑ Number of living units: -------- Number of bedrooms -------- Number of baths -------- Lot size ____________________________________________________________ Water Supply: Public system ❑ Community system [__1 Private 0 Depth to Water Table _�-4 ft. Character of soil to a depth of 3 feet: Sand E] Gravel F1 Sandy Loam gQ Clay Loam [I Clay [I Adobe ❑ Hardpan F] Previous Application Made: Yes ❑ No [A New Construction, Yes J] No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank.or cesspool permitted if public sewer is available within 200 feet.) Septic Tank: Distance from nearest well- �fa Distance from found ti _ /__f on_l_ � _-___.Mate ia!_ __. _________________________________________. No. of compartments______ ______- ---------Size------ /QX i Liquid depth---- ----r-------------Capacity------------------------ Disposal Field: Distance from nearest well-A-60______Distance from foundation_�_o_'-k-----Distance to nearest lot - _ ❑ Number of lines-----------------------------------Length of each line------------------------------Width of trench----------------------------------- Type of filter material-------------------------Depth of filter material-----------------------Total length______._______.________------------------� Seepage Pit: Distance to nearest well----------------------Distance from foundation--------------------Distance to nearest lot line----------------- ❑ Number of pits----------------------Lining material-----------------------Size: Diameter-----------------------Depth--------------------------------- F Cesspool: Distance from nearest well-_______________ Distance from foundation--------------------Lining material___________-.--______-_________-____. ❑ Size: Diameter--------------------------------------Depth---------------------=------------------------------Liquid Capacity----------------------------gals. Privy: Distance from nearest well-_J_-.________________________________________Distance from nearest—building___.____-_--.--_______--. ❑ Distance to nearest lot line-------------------------------------------------------------------------------:--------------------------------------- ---------------- ------ --------� =:�--5 --------------- --- ------------------------------------------------------------ Remod •sng an�/o repairing (des�ribe�= --------- --- ----------------- --------------- •--- --- --------------•--- ---------------------------------- i --------------------------------------------------------------I------------------------------------------------------------------------------------------------------------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 re ulations of the San Joaquin Local Health District. 4 �r ,,�: - _(Owner and/or Contractor ----w' ---------------------------------------------- (Signed)_------------X";7 ---------------------------- ------------- Title R`'T----------- ------------------- r (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 6 - -- - ---------�--"""" - -------------------------------------- DATE------------------ REVIEWED BY----------------------------------- ------------ ---------------------------------------- -- DATE---------------------------------------------------------- --------------------------------- -- BUILDINGPERMIT ISSUED-------------------------------------------- - -------------------------- DATE------------ ----------------------------------------------- Alterationsand/or recommendations------------------------------------------------------------------------------------------------------------=------------------------•----------------------- ------------------------•--------------------------------------------------•-----------•-•-----------------------------------------•------- ------------------------------------------- ••----------------------------- FINAL INSPECTION BY----- -------- -- - Date l SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 30o West Oak Street 132 Sycamore Street 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California ES-4-2M 8-51 Revised W-2100