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APPLICATION FOR SANITATION PERMIT Permit (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 compliant with County rdinan e No. 549f 4 tb) ATIO -- ------ - ---------------- ----------- 74-0-0--- -------- ------- ----- JOB ADDRESS ----- ------—------- Owner's Nam --- - --- - ---- --------- /, ------- ------------ --- ------ •------- -- ----- —------ - - ---- --------- - ------ ----------- Address---- - --- - I ------------ -0 TO ------>?77--------------------------------- Contractor's Name.- ..-----• ---------------- ------------------------------------------------------------------------------------------------------------- Phone----------------------------------- Installation will serve: Residence El Apartment House E] Commercial [] Trayflr Court El Motel 0 Other Number of living units: -------- Number of bedrooms -------- Number '6afhs 76 Lot size ------ ------ Water Supply: Public system El Community system E] Pri)Number to Wafer Ta�ay ---� ft. Character of soil to a depth of 3 feet: Sand El Gravel El Sandy Loam P Clay Loam [:] Adobe E] Hardpan ❑ Previous Application Made: Yes 0 No �7 New Construction: Yes T�No Fj TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if publif saw is available within 200 feet.� . 11 r Sept tic k Distance from nearest well to �m ist n e1frS&0Ljn&5j1bn_j0-0M -- ---- ---- ,___Size_1. . .A------ Liq u id depth.____.... ........ -------Capacity_�__;;�- ---- ---- f kic Xr 1004,t rol---------------------------- ------ ---------- Ly No, of compartments------ ......... 00 nn D;s Field: Distance from nearest w ll�e��Distance from foundation isfance to nearest lotin ------ Tr1_7 V Number of lines-- - ,--Width of trench.-____..__ -------- - - - -- ength of each line---------- e Type of filter ma - -- ----- ------"-- t ri epth of filter material-------- ----Total length--- - --- ------------------ Seepage Pit: Distance to nearest well----------------------Distance from foundation-------------------Distance to nearest lot line__.-_--_________ El Number of pits----------------------Lining material-----------------------Size: Diameter--.----------.--------- Depth_---.-------------__------------ --------- Cesspool: Distance from nearest well-----------------Distance from foundation-------- ---------Lining material-,_____________________-__________ Size: Diameter--------------------------------------Depth----------------------------------- - _ ------Liquid Capacity----------------------------gals Privy: Distance from nearest well________________________..._---- ----________Distance from nearest building_-__________-__________--____._...____._ ❑ uilding----------------------------------------- 11 Distance to nearest lot line-------- - w Remodeling ine---------- Remodelingand/or repairing (describe):----------- ---------- ------------------------------------------------------------------------------------------------------------------------ ---------------------------------------------------------------------------------------------------------------I----------------------------:--------------------------------------------------------------------------------- ---------------------------- ---------------------------------------------------------------------------------------------------------------------------------__------ ------------------------------------------------- $ ---------------------------------------------------------------------------------------------------------------------------------------------------------- ---------------------------------------------------- ------------- I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, St laws, and rules nd regulations of the San Joaquin Local Health District. (Signed). ---- --- -- -- - 07_� - ______________________{Owner and/or Contractor) ;. - -------------------------------------------------------------------------(Tith --------------------- (Plot plan, Is w g size of lot, loAtion of system in relation to wells, buildings, etc., can be placed on reverse side}. FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY- ----------------------------------------------------------------------- DATE:::''� REVIEWED BY---------------------- - -DATE BUILDING PERMIT ISSUED,----------V--------I--------------------------- ------ --------------------------- DATE -------------- - ---------(40 Alterations and/or recommendations:--------------------------------------- ------------------------------------------------------------------------------------------------ --------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------- -------------------------------- ------------------------------------------------------------------------------------------------- ----------------------- ------------------------------------------- ---------------- ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ---------------------------------------------------1_1---------------------- ---------------------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 Stockton, California Lodi, California Manteca, California Tracy, California ES-9-2M 10-52 Revised W-2100