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APPLICATION FOR SANITATION PERMIT Permit No. .11K_7--- (Complete in Duplicate) 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 Orcligalce No. 549. 2-12--OF0 JOB ADDRESS AN LOCATION-.._ ------ ---------------------- ------------- Owner's Name-- ----- - ---- ----- --- - - ------------ -- ----_7hone Address------- ----------- --------------- - -------- ---- 4-- - Contractor's Name------------- ---------- --------------------------------------------------------------------------------------- --------------•--------- Phone----------------------------------- Installation will serve: Residence Apartment House 0 Commercial E] Trailer Court [] Motel 00 Other Number of living units: _-f--- Number of bedrooms ---2./Humber of baths )__ Lot size .. . ............. Water Supply; Public system E] Community system E] Private [Depth"to Water TaL�ft. Character of soil to a depth of 3 feet: Sand Ej Gravel E] Sandy Loam El Clay Loam Ej 'Clay E] Aclobe)� Hardpan ❑ Previous Application Made: Yes E] No 0 New Construction-. Yes E] No TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public. sewer is available within 200 feet.) Septi ij,ank• Distance from nearest we€i------------------Distance from foundation____.____._._____-_Material____.______________..__.___-..._______..____-_. No. ateriai------------------------------------------------- No. of compartments--------------------- ----Size--------------------------------Liquid depth------------ -------------Capacity---------- ------------ Distance from nearest well---b..O----Distance from founclafion----—------_Distance to nearest lot line________.___--__-— Number of lines---------------- ----------------Length of each line------ -- --------Vidth of trench------------------ ---------------- Type of filter material----, ~__.._._Depth of filter material----------- length------------------------------------------ r. J4eeep� Distance to nearest well----------------------Distance from foundation-------------------Distance to nearest lot line----------------- ❑ Number of pits -- -------Lining material-----------------------Size: Diameter-----------------------Deptk----------------- --------------- Cesspool: Distance from nearest well-----------------Distance from founddfion--------------------Lining material-______________-______________--_ i ❑ aterial---------------------------------❑ Size. Diameter------------------------------__.____Depth_._____._-------------- --------Liquid Capacity----------------------------gals. _Privy: i _Distance from nearest well___ ---------------------------------------------Distance from nearest building_____ -_ ______________...___.__..____._. El Distance to nearest lot line--------------------------------t------------- ---------------------------------------------------------------------------------------------- Remodeling,*/or r 'ring (describe):-- ez/ .. .... ... ----------------- -- - -------------- --- ------------ ._v..... - - ---- - - - ------ - - ------ -- ---- ------------------------------- --------- ------- ------------- -------------------------------------------------------------------------------------------------------------- ------------------------------ --------------------------------------...... ------------------------------------------ ----------------------------------------------------------------------------------------------------- I hereby certify that I have prepared this application and1haf the work will be done in accordance with San Joaquin County ordinances, Stat laws, and rules and i egulations of the San Joaquin Local Health District. ' (Signed)....- �. ------�•9/,-_ --..r------------------------------------------------------------------(Owner and/or Contractor) By:-----------------------------------------------------------------------------4---------------------------------------- ---------.._(Title)------------------------------------- ------ (Plot plan, showing size of lot, location of sys+em in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY.--------------------------- - -----------------1---------------------------------------- DATE---------------- REVIEWED ATE----------------REVIEWED BY--------------------------------------------- --------j- ---- - ---------- ---- ---- .... ... ---- ------- --- ----- DATE--------- -"/ � BUILDINGPERMIT ISSUED----------------------------------- ---------------- - - --------- DATE---------- ---------------------------------------------- Alterations and/or recommendations:----------------- ----------------------------------- ------------------------------------------------------ -------------I'll,---------- -------------------------------------------------------------------- ----------------------------------------- ------------------ - ------ ------- ---------------- - -- - ------------------I ;;.i ------------------ ---------------------------I-------------------------------------- ----------------------- - -A-------6------4- -----44::.. V .6 -.. ---------- ----------------- -- --------------------------------------- ------------------- --------------------------- --------------- t ----- - ---------------------- -- - - ----------------------------------------------------------------- --- . . awwfw� " FINAL INSPECTION BY:- ... . .............Z................... ........... Date__..._. SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Street 814 North Street Stockton, California Lod;, California Manteca, California Tracy, California E5-4 1454a6 A7WDCD