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1 � \V. W APPLICATION FOR SANITATION PERMIT Permit No. ...�8...v.�_�-_ (Complete in Duplicate) 'a Date Issued ----------------------- Applica-ion 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.�5}4.9. JOB ADDRESS ANDCATI 4____ ____ ___ ___ __ Owner's Name---------- Phone Address---------=------------------ ! 'J,t� ------•---------.-•---•-------- . , - ---- -- ---------------•------------------- Contractor's Name.--------- •----- --- •- - ------- -- - -- -1-------------------- -•------ ----------------------- --- ------ ------- Phone----------------------------------- f Installation will serve: Residence RrApartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ - -- - F Number of living units: _l___ Number of bedrooms A- Numberof baths �- Lot size ------- ------------------------_--_ Water Supply: Public system Community system E] Private E] Depth to Water Table ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ AdobeR �Hardpan ❑ Previous Application Made: Yes ❑ No?�J" New Construction: Yes ❑' No TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) , Sep is Tank: Distance from nearest well_________________Distance from foundation___-----------------Material _____-_---___--_---___-____________- _-__-No. of,compartments---------- -- -------------------------------Liquid depth----- ----------------Capacity-------- Dis a Field: Distance from nearest well-----------------Distance from foundation-------------.------Distance to nearest lot line....-____________ Number of lines--------.--•-----------------------Length of each line-------•--------------------_-Width of trench----------------------------------- ` Type of filter material-------------- ----------Depth of filter material-__-._-_-_------____---Total length---------------- f Seepage Pit: Distance to nearest --------Distance from foundation-- �______-.-..Distance to nearest lot line----------------- Number -----_______--- („ ----- De tn-------�' v\ Number of pits-____f-------....Lining material-6—&Ui ize: Diameter-.-,, p Cesspool: Distance from nearest well_________________Distance from foundation_______.---.........Lining material-_-_-__-______________---__________.- ❑ -----Depth---- ----------------------------------------------Liquid Capacity------------- --------------gals. Size: Diameter ------- -- - Privy: Distance from nearest well____---------------------------------------------Disfance from nearest building--------.-_____________________-______--- Yi ❑ Distance to nearest lot line------------------------- --------- -------------------------------------------------- Remodeling and/or repairing (describe):---------------- ---------=- -------------•-------------------=-------------•----------------- ----------------------------------------------- ------------ --------------------- -----------••-•--------------••------ •------ -----------------•-------------------------------------------------------------------------------------------------------------------------------------------------------------- I hereby certify that l have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State laws, and rules and regulafions of the San Joaquin Local Health District. (Signed) s -- - -------------------------- r Contractor) By:..... Title - -- - - - [ ) -------------------- (Plot plan, showing size of lot, lo,�llon of system in relation to wells, buildings, etc., can be placed on reverse si e). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY4��- ----------------------------- ------ ---------------------------------------- DATE"9, = REVIEWEDBY--------------------------------Z------N;---- ------------------------------ ----- DATE:-; ---------------------------••-----•------------------ BUILDING PERMIT ISSUED-----------�-Cj---------------------------------------------------------------------- ----------- DATE...."� -••- ------------------------- Alterations and/or recommendations:------ ---- - - V _.._ ------------- ------... ... ---•-•--------- -------------------- ----- --- - ---- --•=---- ----------------------------------------------------------------------------- ------ ---- -- - - FINAL INSPECTION BY, fo - �Z 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 145446 ATw000 „tom +