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.I APPLICATION FOR SANITATION PERMIT Permit No. ...L..?�... �N""` (Complete in Duplicate) Date Issued ----��IA_��.... ' u Applica+ion is hereby made to the San Joaquin Local Health District for a permit fo construct and install the work herein described. This application is made in compliance with County Ordinance N 54 JOB ADDRESS AND LOCATIO ---- . . -- -------- ------ ...---------------------------------------------------------- Owner`s Name------ ..-_----------- '._... - - Phone------------------------------------ Address...................................... _, ------------- -- ��-- .-- -- ------�-- ----------------::.......- -- --�--••-----------•-----.. -------- -- -- - - ------ -- Contractor's Name----------------- - .. __ Phone- for t_�-� W Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: _- .. Num er of bedrooms .A-. Number of baths .-0-- Lot -------------- Water Supply. Public system ommunity system ❑ Private ❑ Depth to Water Table ft. Character of soil to a depth of 3 feet: Sand ❑ ravel ❑ ay Sandy Loam Loam E] Clay [-] Adobe Hardpan ❑ Previous Application Made: Yes [-] No New Construction: Yes Ek No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: Septic Ta Distance from nearest well_. __ Distance from fou da,ion._ -.. -------------(No septic tank or cesspool permitted if public sewer is available within 200 feet.) p _� �I� No. of compartments..-x---________Size.. -r--Liquid dept ....._ �-_Capacity--- ---e- Disposal Fie d: Distance from neare well.. Distance from foundation-. -___ Distance to nearest I li fJ`r�----- �, ._.. Number of lines...... t .____- ength of each line....... ---.Width of trench-.... ------------ Type of filter material.n' -,__ _ tDepth of filter material....... ......... .Total length-.-.... -------------:_ See^pa+g�e Distance to nearest well-.-1_ __._.---Distance f rq fou afion... 1, ...._.Distance to nearest lot line---/10....._ LV Number of pits.-.- .:._..Lining material..—Size: Diameter..-.. -, _�__Depth-------Z..5!..-....- Cesspool: D;stance from nearest well-----------------Distance from foundation--------------------Lining material--------------- ------- ❑ Size: Diameter----------------------------- -------Depth----------------------- ------ ------------------Liquid Capacity----------------------------gals. Privy: Distance from nearest well....''-------------------------------------.------Distance' from nearest building------------------------------------------ El Distance to nearest lot line------------- ----------------------------- --------------- ------------------------------------------------------ --------- ------- Remodeling and/or repairing (describe)------ -------- ---- - - - --------- ------ -� -----. ... . --10------ -- ----- ------------- -------------------- ----. ------- - -- ---------------- -----`..+-— - •eE�: -----•-- :-` � ------ 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. (Signed)............_-----------------------------------:-------------------------------------------------------------------------------------------------- -----------------(Owner and/or Contractor) t By-----------------------------------------------`-=--------------------- --------------- -------------------------- -----------..-(Title)---------------- ----------------------------------------------- (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). 4 y. FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY--------------------- ------------------------=---------- DATE------ . ---------------------------------------------- REVIEWEDBY----------------------------- -- -- -------------------------------------------------- DATE------- 1- - -•------------------------------------ BUILDING PERMIT ISSUED-----_----------------------- ---- - --- - --- DATE------------------ Alterations and/or recommendations:-------------- - ---- - -------------------------------------- •-----•---------------- � .........I---------------- ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------- --------------------------------------------------------------------------- ---------------------------- FINAL INSPECTION BY--- -------------- ---•-- ------------- Date. --- -------------------------------- s SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Street 814 North "C" Streat Stockton, California Lodi, California Manteca, California Tracy, California EE---9-2M 145446 A-VM- 1z-54 -