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APPLICATION FOR SANITATION PERMIT Permit No. (Complete in Duplicate) Date Issued f Applica+ion is hereby made to the San rJoaquin Local Health Distr'cf for ' ermit to construct and install the work herein described. This application is made'.in compliance with County Ordinanc . 5 JOB ADDRESS AND LOCA N... - ---- - ' _ 0 ------ Owners NamPhone ' x1 Address f y ! ... : ------------------------------ - : // f'-- - - - - -Contractor`s Name_ -- - ----------------------- Phonp! Installation will serve: iResidence [I 'Apartment House ElCommercial ❑ Trailer .Court Motel ❑ Other ❑ Number of living units:----.- Number of bedrooms _____--_ Number of baths ____.-__ Lot.size __. - -' Water Supply: 'Public system--E] Community. system ❑ Private Depth to Water Table ._a. ft. "_ f Character of soil to a depth of-3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Ciay Loam ❑ ' Clay ❑ Adobe �ardpan ❑ Previous Application Made: Yes.❑ No:ZNevi Construction: Yes ❑ No _ TYPE OF INSTALLATION AND SPECIFICXTIONS: (No septic septic tank or cesspoolpermitted if blic s war is available within 200 feet.) �? Septic Tank: Distance from nearest wel ................. _....=._--=. Distance from foundation........... _Material-------_-___--___.___________._________._______. No. --------------- Q1"q of compartments---------- ----- ------Size----•-•-------•-•---- ----_Liquid depth--------------- ----------Capacity------------=---------- ID , sal Field: Distance fro e ` I - e F .. - --- - - 9-: --------•- Number of I nesearest-wail---------- - Lenath of nce re ch I line-.--.foundationom ___ ______________ W dthcofttrench est lot line Type of filter material--- -------------------Depth of m er;al----------- ---- ---.-Total length------ -------__ -_--_ --- -- d. ! r _ + l .. _ -.. k. p g Dist ce from f un ation... -______.Distance to nearest lot lies __._ -. See a Pit: Distance to nearest well__l��-__.- - - p Number of pits.___------=--------Lining mat rial._ --- Size: Diameter-A�_T----------.Depth.., ._' I ------------------ Cesspool: Distance -from nearest well_______________F Dis . ce from ndation____--.--_----_-_lining material-------- .-__.__°.__.___�---------_. ❑ Size: Diameter_ ----=-----Depth -- ------------ _-Liquid Capacity --,W- als. Privy:, Distance from nearest well--- -------------------- Distance from nearest building-_-------_----.------__--_____ -__-.-. ❑ 'to"nearest lot line r —------------------------- -------...... ------} -------------------------------------------------------------- Distance Remodeling and/or repairing (descriilje) -- °-- 1 _-------•-•------ •---------,-----•------------------------`-------------- - ------------------------=------------_--------------=----------•---._._----__...-------....._-------------•-•----------- ------ -- ------------------------------------------------------------•--------------------------`-•-----------------`-------------•-'-- -------------------------------- -------------- i certify that 1-hive-,prepared this application and-that the work will be done in accordance with San Joaquin County ordinances, S ate la s,: and rules and-regulation of the San Joaquin ocaI Health-District. 1 - ` antractorJ - (Signed)-_Q_- - ---- ------ --- - fBy:--------- = --•--- - l -----------------=---------------------- --------------(Title)------- -------M----------------------- (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 ----- ---- --=--- ------ �_ -------------. DATE I :. DATE- ------------------------------------------------•---- REV REVIEWED B�--ACCEPTED BY--�-�` ----- -------------------------`- --------------------------._....--------=---•-=----- ?,a BUILDING PERMIT ISSUED DATE ... •--------------------- Alterationsand/or recommendations:----±----------------------- ---------------•----- = --------------------------------------------------------------------------------------------------- i 4 - - - - ` ______________________________________________________________________________ ___________________________________________________________________________ _________•--__-__-------_--_____-_-_____. .- .-------------- ___..____..... _...------ _--- --- --- --- ._________----------------------------. ____.......- ---------------------------------------------------------------•---__-----_-__-----_-_-_-------__--.---.----_....__`---_ .-- __-----__.......... -------- _--__.-_---------_._._.---------- -- ------- -------------- - L�f . z FINAL INSPECTION BY:-----=--------------=- ----V----w .--- Date - = - " 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-9-2 Revised W-2IW