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APPLICATION FOR SANITATION PERMIT t Pdrm'it No. �4i$...l____ i \� (Complete in Duplicate) Date Issued Application is hereby made to the San Joaquin Local HealfbeDistrict for a permit to construct and install the work herein described. 1 Th41 is application is made in compliance with County Ordigaar ce o 49. F JOB ADDRESS AND LOCATI N---- "f. l ----- ---------------------------------------------------------------- Owner's Name_. --- --------- -- ----- •I----- ------------------------------------- ------------------------------------ Phone-----r-------------------•--- . _� _ Address.........-- ---:--- ----- - � -----•----------------------------------------------------=-------------- -------------- Contractor's Name------- ---- ---•-- • --------------- --=------------------------------•---- ---------------------'---------------------- Phone----------------------------------- Installation' ---------- ------Installation will serve: Residence Apartment House ❑ Commercial ❑ Trail Court Motel ❑ er ❑ -1 b ' :_ Number of living units: ___ ___ Number of bedrooms _ __-_ Number r aths ________ Lot size Water Supply: Public system ❑ Community system ❑ Private Depth to Water Table -------- ft. Character of soil to a depth of 3 feet: [Sand Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe Hardpan E]! Previous Application Made: Yes E] I New Construction: Yes 2'00-No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: , (No septic tank or cesspool permitted if p blic�se'wer is available within 200 fe .) I Septic Tank: Distance from nearest well ___.___Distan jfromy�fbund ;n__--._____iJ...__.Mate ia�_____________ _ ❑ No. of compartments______-_:r�__!_ .__Size_ _ __vl __,Liquid depth'_________._______--_Capacity__ Dispos I Field; Distance from nearest elt/_ .....Distance from foundation-"_ Y.-_L___.bistance to nearest lot li + Number of lines_________ ,___' -------- Length of each lin e_______._- _ _ _ Width of french-------- ? Type of filer materia i_ ti Depth of filter material--__j__ - _-_.Total length--------!__z_a_._______________._ Seepage Pit: Distance to nearest well______ _____ _____ __Distance from foundation------------- Distance to nearest lot line______..__--__--_ ❑ Number of_pits--------------- material-----------------------Size: Diameter----_------------------Depth--------------------------------- Cesspool: Distance from nearest,well-----.-- - -I-Distance from foundation----- ---------------Lining material____ _._____.____________ _, ❑ Size: Diameter------- ---- A-- ----&-Depth--------------------•-------------------------i-----Liquid Capacity- --------------------------gal Privy: Distance from nearest well__.______._____________________________________Distance from nearest building---------------------------------.._____- ❑ Distance to nearest,lot line------------------------------------------------•------------------------------ - ----------------------------------------------------------- R mod ing Od/or repairir�s -iescr --------- -------------------------------------------------------------------------------------------------------- ------ --•------------------- • 7� --" -------- -___------- ` ---------------------------------------------------------------------------------------------------- - ------------------------------- ---------------------------------• ------------------- -------------- I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, St`e,laws, and rules and regulations of the San Joaquin Local Health District. A _�_ ___ ----------------------------------------- 01 'it (Owner and/or Contractor)(Signed)_____________ —---� (Title)------BY � ° ------------------------------- (Plot plan, showing size of lot, locationof system in,relation to wells, buildings, etc., can be placed'on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY DATE- BY--------------------------------- ---- --- ------------------------------------------------------------------------------- DATE BUILDING PERMIT ISSUED- ------ -------------------------------------------------------------------------------------• DATE-- Alterations and/or recommendations: - = - 5- -- -•-------------------•---------------------•------- -----------------------•---------------•----------•--------•---------------------------------------------------------------------------------------------------------•---------•-----------•-----•------------••----- ----------------------------------------- ---------------:------------- --------------------------------------------------------------------------------------------------•-•----•--------------•-• ---------------•--•-_ ------------------------------•------- ------------------------------ •----- ---- ------ t,, FINAL INSPECTION BY: ' = _ Date ) !� ---- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Street 814 North "C" Street �f Stockton, California Lodi, California Manteca, California Tracy, California E5-9-2M 10-52 Revised W-2100