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-3 � F APPLICATION FOR SANITATION PERMIT Permit No. ._�'�...o.l...�� i (Complete in Duplicate) i Date Issued _�/— �_ //.io- 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 Ordinan No, - li , JOB ADDRESS AND OCATION--------- - - " °-- ------------------------------------------------------------- Owner's Name- E__-� -- -- ------ Phone---�� iI Address------------------ ...• --- ------------------ -------------------------------- -- --- Phone--- _. Contractors Name ---- --------- - - ------------ ----------- Installation will serve: Residence Apartment "ouse ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units-1__ ____ Number of bedrooms,.__ Number of baths _/__ Lot size ___________________ Water Supply: Public systemlt Community system ❑ Private ❑ Depth to Water Tabl,_70—ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Ado Hardpan ❑ + Previous Application Made: Yes ❑ Noru" New Construction: Yes No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: , (No septic tank or cesspool permitted if public sewer is available within 200 feet.) l Septic Tank: Distance from nearest well_-ie ____Distance from foundation-----,f&l-------Material ___. -- ----- ____ ._-------_-- /`qpC{ No. of compartments___a�_________________Size__ __ , _Liquid depth___- 3-_--__Capacit _ Disposal Field: Distance from nearest well.,-.-_ ...._.Distance from foundation__/e___ ------.Distance to nearest lot line---.�__--___ Type u of er r lines_______ __________________ _ 1---- - Length of each line_________ � ---------W+dth of trench------- - • ---------- - filter material _____Depth of filter material----l,�f'-'�------Total length______Av._�---___________________ Seepa a Pit: Distance to nearest well.rc ____Distance fro fou afion__-/__�-_-Distance to nearest lot line__-_�rr_�._ Number of pits----- --------------Lining material' r� Size: Diameter__-_�.,� ------Depth-----� '- `___-_-_-_F--• I Cesspool: Distance nearest well-----------------Distance from foundation--- ---- material__-_______-________________-______- p .� ❑ eter------------------ -------------------Depth-----------------------•---------------------------Liquid Capacity--------------- --------gals.; . Privy: Distance from nearest well--------------------------------------------------Distance from nearest building____-_--__-___--_-------____--._..--.--.-. ❑ Distance to nearest lot line---------------------------------- --------------•---•---------••-__-__._----------------------------- ---------------•----------------------- u Remodeling 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, Stat aws, and r les and re ions of the San Joaquin Local Health District. i (Signed)------ ----- ----- --- ---------------`----------------------------------- ---------------- --------------- Owner and/or Contractor) By:_--------------- ----- :1- :---------------------------------------------•-----------------•---------------------(Title) .r (Plot plan, showing size of lot,-!,ocation of system in relation to wells, buildings, etc., can be ed on reverse side). ,1 0 FOR DEPARTMENT USE ONLY ` APPLICATION ACCEPTED BY-------------------------------- DATE--------- -- rG - REVIEWED BY------------- DATE BUILDING PERMIT ISSUED 'I -------------------------------------- DATE----------------------------------------- Alterations and/or recommendations:-------------------------- -------------------------------------------------------------------------------•-----------•- - - ;I ---------- ------------------------- ---- ---------------------- --------------------------------------------------- --- • ------- --------------------------------------------------------•-------------------- ,l ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- !I ----------------------------------------------------------------------•-------•--------------------------------- ------------------ -- ---------------------------------•--- FINAL INSPECTION BY:----'i p Date---------- /Afl:�? ----------------------- SAN t JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street I� 300 West Oak Street 132 Sycamore Street 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California " E5-9-2M 10-52 Revised W-2100; , '