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APPLICATION FOR SANITATION PERMIT Permit No. (Complete in Duplicate) Date Issued ---- z Application plicafio is hereby made fo.fhe San Joaquin Local Health District for a permit to Construct and insfTithe work herein described. This application is made in compliance with County Ordinance No. 49 t 7-C-1 5-0-v_-� JOB ADDRESS AND, OCATION.------- .tleuw_-- Owner'sName.__._____ t&--- /o------- 1 ------- --- - ------ t Name------- - -- -------- - ---------- -- ---------------------------- ------------- one Address----------- ------= -- ------------------ --------- -------*--------------------------------------------------------------- ------------------ ------ Contractor's Name ----------------------------------------------------------- Phone-------------- ----------- Installation will serve: Residence E] Apartment House E] Commercial E] Trailer �Cour t [] Motel El. Other Number of living units: -------- Number of bedrooms -------- Number of baths _Y2�_ 11 Water Supply: Public system [] Community system El Private [Depth to Wafer Table _,,525ff. Character of soil to a depth of 3 feet: Sand [] Gravel [] Sandy Loam B---Clay Loam, 0 Clay [I Adobe ❑ Hardpan ❑ Previous Application Made: Yes 0 No M-- 'Nw Construction: Yes El No RFMA/VA: Yes E] No F] TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or'cesspool permitted if public sewer is available within 200 feet.) 'an�, Distance from nearest well_______.___.__--_Distance from foundation--------------------Material Wan', No. of compartments---------- ---------------Size--------------------------------Liquid depth---------- ----------------Capacity----------------------- "Id ield: Distance from nearest well_________________Distance from foundafion--------------------Distance to nearest lot line__----__________ V0 Number of lines-----------------------------------Length of each line------------------------------Width of trench------------------------- ---_ Type of filter material__-_____ __Depth of filter material___________________?---Total length-------------------------------- Seepage Pit: Distance to nearest WeIIAK....__DisfaO��m pundafion---/,&0-------Distance to nearest lot Number of pits___._ -________"Lining----------Lining material- K------Size: D ia mete r_.ZVO----_// - --------Depth------ Cesspool Distance from nearest well------------- --Distance from foundation_._.___-------___ Lining material------------------------ ❑ Size: Diameter---- ------ ------ -------------------Depth--------- -------------------- --------------- ----Liquid Capacity.. ------------- ------gals. CC Privy: Distance from nearest well___________________________-_ ---.___.___-_____Distance from nearest building------------------------------------------- ElDistance to nearest lot line__---"-."_____.______ -------------------- --------- --------------------------------------------------- Remodeling and/or repairing (describe):---.-- - -----I�Zvt---- �_ ------- ---------------------------------------------------------------------------------------- ------ ---- - -4------.a-.....c_ ------ ---------------I------------------------------ ---------------------------------------------- -------------- ------------------------------------------ ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------ I hereby certify that I have prepared this P11 nd that f he work will be done-in accordance with San Joaquin County ordinances, Sla ws, and rule and r ulationsp e, Sa Joaquin Local h District. (Signed)------ ---- - - ----- . ......... ------------------------------------------------ (Owner and/or Contracfor) By:----------------- e� ------------------------------------------------------------------------------------------------------------------(Title)---- --------------------------- (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY_______________---- --- DATE________ E------- - ------------ -- B -------------------REVIEWED BY--------------------------- ------- ------------------- - ------ TE---------- A UILDING PERMIT ISSUED---------------------------q------- ------------------------ ------------------------------ DATE--------------------------- --------------------------------- Alterations and/or recommenclafi4ps.------------- ---------------------- - -- ---------- ---- ---------------- ---------------I ----- --- ------ - -- - - -- - - ------------ ---- ----- --tW -- - - ---------- - ------------ ---------- ---14-en-'N't-------- -- --------- -------- ------- ------- - ---------------- ---- ------ ------- g---------------------------------------------- .:--- -------------d�----------------------------------- -------- FINAL INSPECTION BY:_________ --------------— --------------------------------- Date--- --------- - -- SAN at-------------- 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 Revised 1.57 F.RCO.