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APPLICATION FOR SANITATION PERMIT. Permit No. - � (Complete in Duplicate) ' / 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. 54 • JOB ADDRESS AND LOCAT N.-__-_-_ -_3� ----------------------- ----- ` -- -- Owner's Name---------- -`--------------��'-'��i �._ ...,.. _ _.... �„ Phone Address s ------------- -- � _Contractor's Name ----------------------------------------------------------- ---••- l .---------•----------' ------------------- --------- ----------------------------- -------------- Phone--.-.Installation will serve: Residence O/hpartment HouseCommercial E]❑ Trailer Court ❑ Motel ❑ Other Number of living units: _6X Number of bedrooms - r - Number of baths -_ - Lot 'size _- - Water Supply: Public system, Community system ❑ Private ❑ Depth to Water Table _��_ft. Character of soil to a depth of 3 feet: Sand [] Graver❑ Sandy Loam p Clay Loam ❑ Clay ❑ Adobe B—Hardpan ❑ Previous Application Made: Yes ❑ No Construction: Yes []K�No H–___F'HA/VA: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: t (No septic tank or'cesspool permitted if public sewer is available within 200 feet.) AEC Na. of compartments - - Tapk: Distance from nearest well------_ ---- on-_.----_----- Distance from foundati --.Material------------------------ •-•------------------- ------------------Size-----`-----------------•----:--Liquid depth----------- Capacity spaisal 'ield:` Distance from nearest well-------------------Distance from foundation--------------- -----Distance to nearest lot line 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 well ---Disfanc rom oundation..-(_Q_�.•t_.Distance to nearest lot line------ ------- ---_°Z-- -� 0' Number of pits-------/--_-- _ Lining material--- - -----Size: Diameter-----�,9--_------Depth......2.�--`------------- Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material-------------------------- ❑ Size: Diameter------- ------------------------------Depth------- ---------- ----- --- - -_ .. ----------•- - - - ---- - --------- Liquid Capacity-- ----•------------------gals, I Privy. Distance from nearest well-_---_-------------------------- ---- g- --Distance from nearest buildin A 171 Distance to nearest lot line--------------_-.__----: ----------- --------- - Remodeling and/or repairing (describe):-------------------------------------- ---------------- -------------------------------• ---------------------------------------------------------------------------------------•-------•------------------------------------------------ ---------------------------------------------------------------- I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State laws, and rules and regulations of the San Joaquin Local Health District. (Signed)------ r. = t ------------------------- (Owner and/or Contractor) BY: ;-----------------a. ----- - w ------•---------- ------ -----{Title)---- (Plot plan, showing size of lot, location of system i relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY a-k�a-:C?---------------------------- DATE --- ----REVIEWED BY---=---------�---- - -- -- - ----- ---- DATE BUILDING PERMIT ISSUED --------- ------------------ Alterations and/or recommendations: - - - -DATE - - ----------------- ---------------- ! -- ---------- ---- ----------------- ----- ----- FINAL INSPECTION B ---_--- ---- Date--------------- ----7- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Sfree+ $14 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California ES-9-2M Revisea 1-57 F.P.CO.