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r APPLICATION FOR SANITATION PERMIT Permit No- _ _____ __________ r (Complete in Duplicate Date Issued __ 7�__'{�-� Applica{ion is hereby made to the San Joaquin Local Health District for a permit to construct a d4ristall the work herein described. This application is made in compliance with County Ordinance No. 54 , 1=�� ---------------- ,I-------------------------- JOB ADDRESS, AN ATION_ _____ _� "__ _--- f �� ' - d Owner's Na `-- •��----- -•--� - -----------------------------------"--------------- -------------------�----- Phone--- - Address •--- ----•-• ------ ----•-------------------- ------------------------------------------------------------------------��------------ Contractor's Name "------------ Phone------------- . Installation will serve: Resid ce parfinent, ouse ❑ Commercial ❑ Trailer Court ❑ .Motel ther. ❑ Number of living units: _____ Number of bedrooms __,2-i'9`umber of baths __�_-- Lot size -_ - s�,rPh-___________--__---__ Water Supply:_ Public system ❑ Community system ❑ P'rivatex Depth to Water Tabft. Character of soil to a depth of 3 feet: Sand Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ AdotqV Hardpan Previous Application Made: Yes ❑ New Construction: YesNo El TYPE OF INSTALLATION AND SPECIFICA NS: • (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tank: Distance from nearest well_________________Distance from foundation-----------.--------Material----__________________-_----_-___-_-"____--____- ❑• No. of compartments-------------------------Size---•---------------------------Liquid depth---------------"----------Capacity---------------------- - Disposal Field: Distance from nearest well-----------------Distance from foundation--------------------Distance to nearest lot line______--_______- -� ❑ Number of lines-----------------------------------Length of each line------------------------------Width offrench-----------------_____.------ Type of filter material--_-__-_ --- ---- - -Depth of filter material--------------.--------Total length_____________________""_______-_ � � / See a e Pit: Distance to nearest well__ ---�2.______,_Distance fr m,.fou dation___ _��.-_______.Distance to nearest p Number of pits___.,-- .-_---__ imn �materir _Size: Depth... fX_''. -__-___ Cessp I: 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-------------------- ------------ ---------- ------------ ----------"---------------------------------------------- r ---------- Remodeling and/or repairing (describe):_... ` �---- ------- ------ -------• ---------------- -------------•- ----------•-------•---_----------- - ---•- -------•------------------------------"------------•--------------------------------------- h1 ---------------------"---------- "---- ------- ------ ------------•------------------------------------------------------------------------------------------------------------------------------- ------------ I hereby certify that I have prepared this cation and that the work will be done in accordance with San Joaquin County ordinances, Stoelaws, andles a d regul ions the San Joaquin Local Health District. Si ned ___ J Owner an ori ntra or) BY: -•--•-.....-----•-.- ------ - --------- - ---------------------------•-- ------ -•---(Title} (Plot plan, showing size of lot, IocAtion-a sysf in relation to wells, buildings, etc., can be p ac on`_ev a side). FOR DEPARTMENT USE ONLY �4 APPLICATION ACCEPTED BY* -- ----------------------------------------------------------------------------------------- DATE__,-------•--------------------------- REVIEWEDBY---------------------------- --------------------"----------------------------------------------------------• DATE-- ---------------------------------------.... DATE BUILDING PERMIT IS SUED_t________`x -_-____-. __---__"_ Alterations and/or recommend oas: -^------`---------------------------•-----•-----------------------------— .. ' slit A-A-4 r <' "irs f« ^.-f• r;Fes... ,., i _�ws_.�Y r ._.f A4f-=-- -----•--•--- -- ;... ,--. ' N .» ------------ l�',! .C7�f-✓1 .r. - {� ,}. ter., - L `J � •" ,�r, -----.._--•- -----"---- -----• - r- (�C ------------------------. $ ..... " ... i FINAL INSPECTION BY: " "----•------------------- -------•---- --"- Date SAN JOAQUIN LOCAL HEALTH DISTRICT 130.South American Street 300 West Oak Street 132 Sycamore Street 814 North "C" Street Stoekton, California Lodi, California Manteca, California Tracy, California ES-9-2M ; - Revised W-2100