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APPLICATION FOR SANITATION PERMIT Permit No. .. (Complete in Duplicate) .may s Date Issued ---------- Applica*ion 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 Jn compliance with County Ordina No, 49. JOB ADDRESS AND LOCATION_-i----- -------- - _-- -- ----------------------- Owner's Name. ' ---------------------------------- ----- Phone Address-----------------•------•--- /'.. ` �j Contractor's Name ------------------•---- - ------------------------ -- ------ � Phone!"7= __6--� -�1. •--------------- Installation will serve: Residence Er-A- partment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: /---- Number of bedrooms -p2-- Number of baths --k- Lot size ---- •-- --------•-------- Water Supply: Public system R-1fommunity system ❑ Private ❑ Depth to Water Tabled-- ft. I Character of soil to a 'depth of 3 feet: Sand.❑ Gravel ❑ Sandy Loam ❑ Clay Loam 0 Clay ❑ Adobe Hardpan ❑ Previous Application Made: Yes Ej No CRS New Construction; Yes ❑ No ❑_ TYPE OF INSTALLATION AND SPECIFICATIONS: Y Y 1 (No septic tank or cesspool permitted if public sewer R available within 200 feet.) J -Sep ' _Tank: Distance from nearest well ---.}----.---Distance from foundation--------------------Material---_--------.--_-._----------------------- ----- No. of compartments----- ....... ......L...Size depth----------------- _-------Capacity----------------------- Dis sa. Field: Distance from nearest well_-= _c-_Distance from foundation___-:---..-.------'.Distance to nearest lot line----------------- Number of lines---------.-_--------------------Length of each line----------------------------.Width of trench---------------------- Type or filter material-_'--_..._--.- Depth of filter material----------------------%Total length------------------------------ See a Pit Distance to nearesstt well' -'.-._ Number of pits-: - Lining� Distance �� m fou dation_--- /----_.Distance to nearest lot line---- s-�---- e __- _--.---r material:--- -- -----Size: Diameter_--22-22 ----Depth....a's-------------------- (� Cesspool: Distance from nearest well--------------_-Distance from foundation-----...___.__._._..Lining material_.-- -.- f. ❑ Size: Diameter =-----------=--'------,...-----D&' th-------------------------------- ------------------'Liquid Capacity------------- gals. Privy: Distance from nearest well---------------------------_------------------:--Distance from nearest ❑ building ----- I Distance to nearest lot.line---------- _ - Remodeling and/or repairing (describe)-------------------------------- ------------------------ -•-----•--••------•----------------------------------------------------------------- - - -------•-----------•----------------- -------------- t --------------------•---------------- ------------------------------------------------------•----•-------.------------------------------ --••-----------•---------•-----------------•-------------------------- -------------- 1 I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, St , and rules and regulations of the San Joaquin Local Health District. +f (Signed)-------------- - and/or Contractor} wner a By:---•-------------------- l -------- � 1 - (TitEe}-=------ (Plo+ plan, showing size of lot, location of system in re ion to wells, buildings, etc.,.can•lie"placed on reverseside). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY------------- - ------ - - ---------------- - -------------------------------------. DATE---------=- REVIEWED BY -------- ---------------------------------------------------- DATE---------- -- ••-------- BUILDING PERMIT ISSUED-------------------------------------------------------------------------------------------------•---- DATE------ ----•------------ Alterations and/or recommendations:,-------------- . .. ------ -----------------------------•--------=---------•------------- -'Ns --------------------------- ---- : :: :: : �' - --- ----------- ---------------------------------•----------�---------------------- -------------- ------------------------------------ FINAL INSPECTION BY:----- -------------------- Date----- 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 1 4 ES-9-2IN 145446 ATWOOO 12.54 J r T