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�j17 APPLICATION FOR SANITATION PERMIT Permit No. ____ "D""...- �� y'r (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. This application is made-in compliance with County Ordinance No. 5j2* JOBADDRESS ANOCATION-------------------- ------------ - ---- ------ ------------=------------------------------- --------------------------------=----------- 01 � Phone= Owner's Name--- -------- --------- --------- - ---- ----- - -------------- ---- s Address-------------------------- ------ Contractor's Name------------ "'7,+ -- ----- i---- ------------- --------- ---------- Rhone----------------------------------- Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: __:__ Number of bedrooms 2--- Number of baths ---/__ Lot size - - ----=----------"---------- Water Supply: Public system'[gool(,ommurity system ❑ Private ❑= Depth to Water Table -------- ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam I] Clay ❑ Adobe-�ardpan ❑ Previous Application Made: Yes ❑ No -' slew Construction: Yes No ❑ PHA/VA.. Yes ❑ No ❑ TYPE OF.INSTALLATION AND SPECIFICATIONS: (No septic tank or`cesspool permitted if public sewer is available within 200 feet.) /} Septic T Distance from nearest well - __ Distan from fou cation__,/10-_-------.Mat r;al---------------------------- _ " "7.______. No. of compartments------ �/�,---------Size-- '� . Liquid de�h �---------------- Capacity-----��0 Dislosal e d: Distance from nearest well_CX '�Disfance from foundation��__________.Distance to nearest lot line1l�?_______ Number of lines______ ---"""""--""�p""""Length of each line-_---(�-- -"__________.Width of trench '________________ Type of filter material-----� ------ Tota4 length------ �QlCDe th of flter material fir_ Seepage Pit: .. Distance to eearest well------------'_-------Distance from foundation___________________.Distance to nearest lot line_-____-"_____.___ ❑ Number of pits----------------------Lining material-----------------------Size: Diameter-----------------------.Depth--------------------------------- t° . Cesspool: Distance from nearest well_________________Distance from foundation._.---_.___.____-_.Lining material------------------------------------- ❑ Size: Diameter------- --------------:- ----------- Depth-------------------------- --------------------•---Liquid Capacity--------------- gals. W Privy: Distance from nearest well-_..1____________________________________________Distance from nearesf building--------------------------------------- ❑ - Distance to nearest lot line-- --------------------------- ---------------- ------------ -------------------------- Remodelin and/or repairing describe _---``�- % -------------------------------- - l - _-1-------------------------------------------------------------------------- --- ---- ----- ----- V 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 5egulations of 66,-San Joaquin Local Health District. Jar �'✓ -------------------------------------------------------------- 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----- ------------------------ ------ P DATE r .•-� BUILDING PERMIT ISSUED :---------------- Alterationsand/or.recommendations --------------------------------------------------------•----------•---------------•------------•--•-------•"----------------------------- F ------------------•----------------------•----------• ------------------ ---------------- -----"-•-----------•---------"-•------------ -----"--•-------•----•- ----------------------- ------------------------------------- --------------------------------------------------------- --•----------------------•-------------------------------- ---------•----------------------- ••-------- i -----------r----•-------I--•--------•--•-------------r----•-••------------•---------------'--------------------- Date-------------------- ---------------------- FINAL INSPECTION BY:: --------- ---------- --------------------------•--- i SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Street 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California ES-9-2M Revises 1.57 F,P.CO.