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} APPLICATION FOR SANITATION PERMIT Permit (Complete in Duplicate) G 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. S ... � 0lle y JOB ADDRESS AND LOCATION..__ m --------'".'.'- '�----------------------------------------------------------------------------- t r Owner's Name _ e --- Phone_oZ�_7- _ ------- ----- - --------------------------------- Address ---�2-^�^-•-------•----------- - -- Contractor's Name--------------------------------------------------------- -- Phone --------- Installation will serve: Resident//e V Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: F-____ Number of bedrooms _ ____ Number of baths ,/____ Lot size Water Supply: Public system Community system ❑ Private ❑ Depth to Water Table _ ft. 1 Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay.❑ Adobe Hardpan ❑ Previous Application Made: Yes ❑ No New Construction: Yes f,] No TYPE OF INSTALLATION AND SPECIFICATIONS: f (No septic tank or cesspool permitted if public sewer is available within 200 feet.) 1 Septic Tank: Distance from nearest well_--Distance from foundation_/6________-__.MaeriaL_ __ _____ _________ _____ rNo. of compartments-_-A----------------size--41-4�-_-----.---Liquid depth---3?;-�----------_-Capacity- ------------------ Disposal Field: Distance from nearest well.0)4;AnA4._.Distance from foundation---- ___4--------Distance to nearest lot line___-_______ Number of lines_________0,--------------------Length of each line---A��=___��_�__.Width of Irene __-_7-�----- ----------- Type-of filter material_- p - �_____________ g ______.De Depth of filter material 1 �►- Total length &---0---------------------------- C4 � Seepage Pit: Distance to nearesf well----------------------Distance from foundation------.--------.___.Distance to nearest lot line----------------- 6` ❑ Number of pits----------------------Lining material----------------------.Size: Diameter------------------------.Depth--------------------------------- Cesspool: Distance from-nearest well-----------------Distance from foundation------------------- Lining material------------------------------------- Size: Diameter-------------------- --_De th-------- ------------_ ---_ - -------- ----Li Liquid Capacity ❑ p q ------------------------gals. Privy: .. Distance..from .nearest well..—------------------------------- -=------ Distance from nearest building:=---------------------------=____---_--1. ❑ Distance to nearest lot line---------------------------------------------------------------------------------------------------------------------------------------- f 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, State laws, and rules and regulations of the San Joaquin Local Health District. 3 (Signed "'t` . -_ ,: --------- (Owner and/or Contractor) f ----- 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-------- BY -- ------------------------------------------------------ DATE - �' � —" BUILDING PERMIT ISSUED•------------- ----------------------------------------------------------------------------- DATE--- ------------------------------------------------- Alterations and/or recommendations:--------------------------------------------------------------------------------------------------------------------------------------------------------------- -----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------•------------ ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ -------------------------------- Date----- //_ FINAL INSPECTION BY--------- ------- ---- ----- ----=------ -------------- ------------- r 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 8-51 Revised W-2100