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APPLICATION FOR SANITATION PERMIT Permit No. (Complete in Duplicate) Date /� '3 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 Ni;j, 5491.1 _N2 JOB ADDRESS AND LO50,T ,YN ----- --- -------- ----- Phone--------- -------------------------- Address-------•------------------- Name________________ 5�1`11! ------------ ---- --- ---- 11 ------------ ---------- F,_----------------- --- --- --- -- ----- -------------- ------------------ 4.1t.Phone------ Contractor's Name-------------- --4---- -- ------ - --- - --- - ---- --- -- ----- -- - - 0;0 House _] Trailer Court ❑ Motel 0 Other E] Installation will serve: Residence Apartment Hou e 0 Commercial F ----------- Number of living units: I_ N ber of bedrooms 2_ Number of baths .-/-- Lot size _,0 Water Supply: Public system i��:unify system El Private [] Depth to Wafer Table,;0'_ ff. Character of soil to a depth of 3 feet: Sand P.—Gravel El Sandy Loam gClay Loam [I Clay [I Adobe Hardpan C] Previous Application Made: Yes 0 No V New Construction: Yes [AO'No El TYPE OF INSTALLATION AND SPECIFICATIONS: (0�fee (No septic tank or cesspool permitted if j�� c'� ewer is available within -----------Septic Tan�-� Distance from nearest wen_a ion ._M I --- -- ---------------- ---plvl/ depth__.--------Capacity---- - - -- ------- No. of com. partments—_-Z---------7- -----Size---Z;v0__) __51----Liquid e. ��istance from found&ionJ Disposal Ei4d- Distance from nearest well __ _ --------Distance to nearest lot [in - ------------- -147f- __ -,Width of trench._._________ _----------- or �ines Length of each line_-_7a Number7-0-1 Zl- -------------- )U Depth of filter maferial--/--rr-----------Total length__-_.____ - ---- '0 Type of filter material-- Seepage Pit: Distance to nearest well---_________________Distance from foundation____-_______--_____Distance to nearest lot hne_------ El Number of pits----------:-----------Lining material-----------------------Sze: Diameter-----------------------Depth----- ----------------- Cesspool: Distance from nearest well----------- _ _-Distance from foundation--------------------Lining material__.___________---__________._.__--__ Size: Diamefer-------------------------- -----------Depth----------------------------------- ------Liquid Capacity-------•-------------------gals. ❑ Privy: Distance from nearest well------------------------------------------------- Distance from nearest buildin ----------------------------- F-1 Distance to nearest lot line------ . .. ......... ---- ---------------—------- ---------- --- --_------------------------ Remodeling and/or repairing (describe'):--.--------- ---- ---------- ------ ------ --- -- ------ 4-----------�; ------- ------------ -------------------------------------------------------------------------- ------------ ------------------------!---------------------------------------I----------------------------------------------------------- ----------------------il-I---------------------- ------------------------------------------------------------------------7----------------------------------------------------------------------------- 1! - --------------I------------------------------------------------------------------------------------------- -----------------------!.--:---------------------------------------------------------- --------- ui I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaqn County ordinances, state lays nd rules and gulations of the Sa Joaquin Local Heal ffi District. (0*- ------e-- - -- ----- -------- ---(Own n /or actor) {Signed).. --- ---- ------- --------- . . . ..... ----------------(Title)-------- - - - ---------- ... ----------------------- (Plot ------- -------- -- - - -------------------------------------- 0;cation (Plot plan, showing size of lot, ;cafion of system in relation to wells, build.ings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY---- --- ------------------- DATE--------------- - -------------------- REVIEWEDBY------------------------------------------ - ------ ----- -------------------------- ----------------- DATE---2- --- ---3------- ----------- BUILDINGPERMIT ISSUED-------- -------�_-I____ ----------------- DATE----------------------------------------------------------- Alterations ATE------------------------------------------------------------- Alterations and/or recommendations:------------------------- -------- ---------------------------------------------------------- -------------------------------------------------------------------------------------- -------------------------------------------------- ---------------------------------------------------------------------- ------------- -- ---------------------------------------------------------------------------------------------------------------------------------------------------------------- ----------------I-------------------------------------- ----------------------------- ---------------------------------------- ---------------------------------------------------------------------------------- -------------------------- --------------------------------- --------------------------------- ----------I-------I------------------------I---------------*1--------- -------------------------- --- --------------------------------------------------------------- - Date- ------ FINAL INSPECTION BY:---------------4 -- ----- ------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Street 814 North "C" Street If Stockton, California Lodi, California Manteca, California Tracy, California E5-9-2M 10-52 Revised W-2100