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l r APPLICATION FOR SANITATION PERMIT Permit No. (Complete in Duplicate) Date Issued --------------- A -----________ Application is hereby made to the San Joaquin L"HDi, t for a permit to construct and install the work herein described. Thiapplication is made in compliance with Coun .JOB ADDRESS ANDLOCATION----- Owner's Name-------�� 9 ---------------------- -------------------- - ------ Phone - ---=--- . Address-------------------•-- Lr Contractor's Name--------- �- !�A"� ---$.. ` `1 Phone._ D ' .' ��-------- Installation will serve: Residence [Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: __ - -- Number of bedrooms _y__--_ Number of baths --!___ Lot size ------<Ci?--- __,K,----- ---�__ Water Supply: Public system ommunity system ❑ Private ❑ Depth to Water Table 10 Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay E❑ Adobe 8--/Hardpan ❑ Previous Application Made: Yes ❑ No ❑ New Construction: Yes ❑ No [] FHA/VA: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: o septic tank or'cesspool permitted if public sewer is available within 200 feet.) r�cnk: Distance from nearest well------_----------Distance from foundation--------------------Material ______-___--___________________-----________. o. of compartments--------------------------Size---------------•----------------Liquid depth--------------------------Capacity---------------------- isposal 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 / Seepage Pit: Dis#ante to nearest well_ __�------------Distance om oundation_rQ---------Distance to nearest lot li e---- - Number of its �'j. p� p ,� _ ______-_Lining material__ --__ ---------Size: Diameter___ _ Dept h --_-- Cesspool: Distance from nearest well-----------------Distance fro foundation--------------------Lining material-__--.____________.________---______ ❑ Size: Diameter-------------- *----------------------Depth----------------------------------------------------Liquid Capacity----------------------------gals. 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 ordinance , a e ws, and rules a d regulations of the San Joaquin Local Health District. I� (Sign - - 4 1-*-------- - -- -- - ---------------------------------------------(Ow��Contractor) By:------------------------------------------------------------------------------------- ------- --------------(Title)---------------------------------------------------------------- (Plot plan, showing size of lot, location of system in relatio wells, buildi s, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY---------------------- --------- -------------- -- --- - ------------------------------------ DATE--------------- REVIEWEDBY------------------------------------ -------- ----- ---- ---- - - - - --------------------------------- DATE----- --• BUILDING PERMIT ISSUED------------------------•---------------__-- -------------------- --------- DATE---------- . Alterationsand/or recommendations----------------------- ------ ------------------------------------------------------------------•------------------------------------------------------------- r - `_ _ _ __ - - ----- -----------, � --------------------------------------------------- FINAL INSPECTION BY:-- ----- Date---------------------0 o�C1 O SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street Sao West Oak Street 132 Sycamore Street 814 North "C" Streef Stockton, California Lodi, California Manteca, California Tracy, California ES-9-2M Revisea 1.57 F.P.CO.