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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 5 9. JOB ADDRESS 1AND L ATION . .___ , Owner's Name--- �. l�trl ----------------------------------------- - ------------------ Phone----------------=------------------- 71 Address--------------------- ------------------------------------------------------------------------------------------------------------------------- Contractor's Name------------------If-- ----------------------------------------------------------------------- Phone _ _/-.-/,,o��7------ 1 Installation will serve: Residence 9--Apairtment House ❑ Commercial [] Trailer Court ❑ Motel ❑ Other ❑ Number of living units: _`__ Number of bedrooms _ -_ Number of baths ---/-- Lot size __57" ------------------------------ Water ----__________________________ Water Supply: Public system Community system-[] Private ❑ Depth to Water Table 3®_ ft. Character of soil to a depth of 3 feet. Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe Hardpan ❑ Previous Application Made: Yes ❑ No 2"New Construction: Yes ❑ No �A/VA: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: w� (No septic tank or'cesspool permitted if public sewer is available within 200 feet.) pti nk: Distance from nearest well_________________Distance from foundation--------------------Material ____--_.-----_--_.___._____________._____._____- No. of compartments------ -------------------Size------------------------------- Liquid depth--------------------------Capacity---------------------- Disposal Field: Distance from nearest well/__._Distance from foundation___ ._____.Distance to nearest lot line______---_____ ___ Length of each line_______ a�________.__ Width of trench--------2�_`y__________.____ Number of lines------------�.-_--_ g - - it i Type of filter material_____!. _- ----Depth of filter material_-__/9_.---_______Total length------4/p---------------_--__________ � Seepage Pit: Distance to nearest well_L C`".._..___Distance~frpm foundation___`4.._______.Distance to nearest lot line__.---_-_--_-____ d Number of its----- Linin material__ C.__ -. Size: Diameter____�_3.____..----Deptn�D..�_________________ Cesspool: Distance from nearest well-----------------Distance from foundation--------------._-__.Lining material-------.---.--.____._________________ ❑ Size. Diameter--------------------- ---------------Depth.--------------------------------------------------_Liquid Capacity---------------------------gals. Privy: Distance from nearest well ___________________________---_-----------------Distance from nearest building---------.-------------------_________._. ❑ Distance to nearest lot line----------------------------------------------- -------------------------------------------------------------------------------- 9 r Remodelingand/or repairing (describe);------------------------------------------------------------------------------------------------------------------------------------------=------------- ------------------------------------------------------------- --------------------------------------------------------=------------------------------------------------- ------------------------------------------------------------------------------------------------------------------ I hereby certify that I have prepared this application and that the work will be,done in accordance with San Joaquin Count ordinances at laws, and rules and regulations of the San Joaquin Local Health District. t --- -------------------- - 5---------------------------- (Owner and/or Contractor) (Signed) By:---------------------------------------------- -� {Title) r ---------------------- (Plot plan, showing size of lot, location of system in,relatio to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY DATE5-7 r ---------------------------- i. REVIEWEDBY---------------------------------------------------I----------------------------------------------------- -------------------- DATE----------------------- -------- BUILDINGPERMIT ISSUED----------------------------------------------------------------------------------------------------- DATE---------------•--------------------------------------------- Alterationsand/or recommendations----------- ------------------------------------ -----------------------------------------------•-•---------------•-•---------------•--------------------------- -----------------•-------------------------- ------ --------------------------- ...�---------- t -� ------------------------------------- ------------------------------ --------------------- F,_ -------------------- �_P7�----- -(- -- -'s-------------------------------------------------------------------------------------------1?^.. ------------------------------------------------------ ----= ------------------ ------ ---- -- ---------------------------------------------------------------------------------------------------------------- 4 FINAL INSPECTION BY` �- - --- --------- - --- - ''1 Date------- � 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 Revises 1.57 F.P.CO.'