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APPLICATION FOR SANITATION PERMIT Permit No. ------ .__ (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. 5449. JOBADDRESS AND LOCATION--------------�-'I/-----:3 -- r-------A-e, '------------------------------------------------------------------------------- Owner's Name--------------------- --------- ----------------------------------------------------------- Phone------------------------------------ ------------ Address------------------------------- < --••------------------1------`---------------------- ------------------- --------------- Contractor's Name--------------•--_---- --------------------- -------------------------------------- Phone-----`•-- ------------------------- y � Installation will serve: Residence JZ Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: _/___ Number of bedrooms -------- Number of baths ------- Lot size -----/____ X____�___ _____ __.__._.--._ Water Supply: Public system J4 Community system ElPrivate ❑ Depth,t Water Table _ ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel [-] Sandy Loam ❑ lay Loam ❑ Clay ❑ Adobe [4 Hardpan ❑ Previous Application Made: Yes ❑ No ® New Construction: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: I I (No septic tank or cesspool permitted if public sewer is available within 200 feet.) I r Septic Tank: Distance from nearest Distance from found�tj�n___ld_____-__.Materiy_j______._.._ No. of compartments--------.-`�:---------Size_- 1 -- - -5- Liquid depth- --- --------- -- i Disposal Field: Distance from nearest weli_5D/._Distance from foundation --1d� Distance to nearest lot line-----�.__._____ ® r Number o{ lines__________.- _Length of each line_ 1-- ?_ fes.-.Width of trencc��-�_________.__-____ Type of filter material--_- Depth of filter material___ --TTofal length'.-_-_Y-;Z ______________________ ! JV Seepage Pit: Distance to nearest well-------------_--------Distance from foundation-___________---____.Distance to nearest lot line----------------- ElNumber of pits----------------------Lining material--_--------------------Size: ;Diameter-_-__------------------Depth...... ------ ' Cesspool: Distance from nearest well-----------------Distance from found,ationt------------------ material---------------.__._._______________ ❑ Size: Diameter--------------------------------------Depth------------------ ------------- ------------------Liquid Capacity..--------------------------gals. Privy: Distance from nearest well-------------------------------------------------Distance from nearest building-------------------------------------- " ❑ Distance to nearest lot line----------------------------------------------- ------------------------ ------ - --------------------------=--------=---------------- ------ Remodelingand/or repairing (describe)-------------------- ---------------------------- ----------------------------- ----------------------------------------•-------•--- -------- I �• -------------------- ---•-------------------•-------••-------------------------•----------•-------------------------------------------- ---------------•-------------------------------------- ---------------------------------------------------------------------------------------------------------------------•------------ ----- ------------------ ---i----------------------------k ------- ------------------------- ------------ --------------------- ----- �y.,.- .- -„ -=---- I hereby-certify that I have parred4is application and that the work will'be done in accordance with San Joaquin County ordinances, to aws, and rules andregulations of the San Joaquin Local Health District. (Signe d) ---- ----- ------------------------ ---- ------- ---------------- --------(Owner and/or Contractor) --- By:--•----------•---------•--------------•-------------------------------------I------------------------------------------------------(Title)------ ------------------------= ----------------------------- (Plot plan, showing size of lot, location of system in relay ion to wells, buildings, etc., can be placed on reverse side). w FOR DPA MENT USE ONLY APPLICATION ACCEPTED BY---------- ---- r-- - �---------------------------------------------- DATE-------- REVIEWEDBY---------- --------------------------------- --------------------- �------------------------------------------------------- DATE----------------------------------------------------------- BUILDINGPERMIT ISSUED------------------------ ----------------------- ------------•---- ---------------------------------- DATE--------------_------- ------------------------------------ { Alterptions and,or recdmm�rdatibris —' - ---------- ------- ----------- -- aY-- � --- - ---- ----------- ------------------------------------------------------ -------------------------------------- ----- FINAL INSPECTION BY___________ _�__._____-. --------------- 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-9-2M 10-52 Revised W-2100