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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 compliancewithCounty Ordinance'No. 5 o. A r JOB ADDRESS A L CATION_____!-_ _ t- �r -------------- ---- --------------------------------- _ Owner's Name__.. F:1 -_ ° � _ ------- ---------------------- Phone__2_-- C9 ? ---- Address---------------- ' Contractor's Name ? ? ---------------------------------------------------- ----------------------------- Phone----------------------------------- ------------------------- Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel E] Other ❑ Number of living units: __1_-__ umber of bedrooms __Z- Number of baths _______ Lot size -___ _ nn x 1 �_I�- ---------------- ` Water Supply: Public system �ommunity system [] Private ❑ Depth to Water Table -------- ft. 1 Character of soil to a depth of 3 feet: Sand Gravel ❑ Sand Loam Clay Loam Clay Y Y ❑ y ❑ Adobe �ardpan ❑ Previous Application Made: Yes ❑ No New Construction: Yes �o ❑ TYPE OF INSTALLATION SPECIFICATIONS: , (No septic tank or cesspool permitted if public sewer is available within 200 feet. 1 t ,' Septic Tank: Distance from nearest wail___ Distancefro foun ion__--l:0_- Mater'a i No. of compartments-------------lL,tSize__`T--A- _-- Li uid de t�-_-----_-- Ca acit q y �--- -- p Y tJ - Disposal Field:' Distance from nearest well____— Distance from foundation___fk�_ 1 Distance to nearest lot line ---------- Number of lines_---______- _y}� Length of each line--------�__t�_ Width of franc h-----_____-- Type of filter material.,_A. +,:';; Depth of filter material___._----�r_r_______Total length--------/-ZP--___-------------- Seepage Pit: Distance to nearest weft-------_--------------Distance from foundation--------------------Distance to nearest lot line_-_________-_____ ❑ Number of pits----------------------Lining material-_---------------------Size: Diameter-----------------------Depth--------------------__ ----------- Cesspool: Distarc6 from nearest well-----------------Distance from foundation----------.-------- Lining materialSize:.Diameter---- Det Privy- Distance from nearest well------------------------------------------------- Distance from nearest building---_______-_______--_ --------------------- ❑ Distance to nearest lot line------------------------------ ------------------- -------------------------------------------------------------------------------------- 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. /j a (Signed)..-�� -- -- ,.---- f --_ -------------- --------(Owner and/or Contractor) By------------------------------------------------ Title ---------------------------- ------------------------------------------------------ - ----------------------------------------- ----------------------- ot 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 WED BY ------------------------------- --------------------------- -------------------------- DATE - I DING PERMIT ISSUED--------------------------------------------------------------------------- ------- DATE--------------- ` ------------------ ------------------------------------- ------ - ---------------- ---------------- terations and/or recommendations___________________________________ ------------------------------------------------------------------------------------------------------------------------------------------------------ --------•------------------------------------ FINAL INSPECTION BY:_-P16 `- -- Date �_ _ ' / ----i-------------------------------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Street 814 North "C" Street S+ockton, California Lodi, California Manteca, California Tracy, California' ES-9-2M B-51 Revised W-2100