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APPLICATION FOR SANITATION PERMIT Permit No, -' -----.---.- �� (Complete in Duplicate) �U 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. 9. JOB ADDRESS AND LOCATION— � _______ --------------------------------- Owner's Name ` a Phone jAddress -------------------- ........ z----`--- r---....----------------------------------------------------------- _.:-� + f Contractor's Name---------------- Phone-----•�--- ---- --------------------------------------------------------------- -- Installation will serve: Residence Apartment Mouse Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ F Number of living units: --_ - Number of bedrooms Number of baths j---- Lot size ---.---6-4---' Water Supply: Public system ❑ Community system ❑- Private PC Depth to Water Table -------- ff. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ 4,dobejgL Hardpan E❑ Previous Application Made: Yes E] No New Construction: Yes ❑ No ❑' � ��r/ N[?[11 TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic TTa k:1` Distance from nearest well-----------------Distance from foundation-------------------.Material-------------------------------.-------.--------- ` FaX KI U6 No. of compartments---------- -----Size-------------------------------Liquid depth- ----------------------Capacity----------------------- Disposal Field: Distance from nearest welw_c f-....Distance from foundation---- -1 -.-.-.Distance to nearest lot line---� x-- ej&& - r(Cl Number of lines---I-------- Length of each line_ Q .-----.-.Width of french__.__��"_------------- p -ii---------- aE :- �A s Type of filter matenal--��.--Pk.-:-Depth of filter material------- length,5�---------------------- ----�_ Seepage Pit: „Distance to nearest well----------------------Distance from foundation--------------------Distance-to nearest lot line---------------- ElNumber of pits---------------------Lining material------''�-------------Size: Diameter-----------------------Depth---------------------------------. 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------------------------------------------------------------------------------ ------------------------------------------------------------ Remodeling and/or repairing (describe):--------- ---------------------------- --------------------------------------------------------- -------------------------------•------ --------------------•---------------------------------------- ------ -----•-•----------------- --- ------------,----••-------•-••------------•----------------------•---------------------------------- -------------••------•---------------------------------- - ---------- - •--•---------•- -------•---- ----.•---•------.......-.---------•----------•-------------------------------•----------•-------------•------- -- --------•-----•----------------------------------- --�-- -------------xPi - I hereby certify that I hay prepared thi applicat on and hat the work will be done in accordance with San Joaquin County-- - ordinances, State laws, and rul +o of th San aquin Local Health District. (Signed)-----------'------------------------ ----- {�r Contractor) BY== --------- -- - - -- (Title)-------------------- ------- ------ --------------------------------------------Title - (Plot plan, showing size of lot, location stem in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY- DATE-�----------------------------------------------------- ---------------------------------------------------- -- ---- ----- ----------------- REVIEWED BY---------------------- ----- - ------- -- -- ----•-------------- ----- DATE--.V ----------------------------------------•------ BUILDING PERMIT ISSUED---------------------------- ------------------------------------- DATE. V------------------------------------ ---•------- Alterations and/or recommendations---- ------------------------------------------ ------------------------------------------------------•---- -•---•----------------------------------------------------------------------------- --------------------------------------------------------- ------------------ ------------------------•---------------------------------- ----------------------- ......................•--•------..................................... •••'•------------------ ------------- ------------------------------••-•-•----------------••-•-------- --- -------------------------- ----------••---------------"-"-----•-----------"--•-"------...-----•---"-------•--------"--------------"--"•-• •------------------------------------------------------------------------------------------------ ------ Vh i FINAL INSPECTION' B :. Date :------------------ 1 SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 30D West Oak Street 132 Sycamore Street 814 North "C" Street ! Stockton, California Lodi, California Manteca, California Tracy, California fi .- l ES-9--2M 10-52 Revised W-2100 F