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-APPLICATION FOR SANITATION PERMIT Permit No. (Complete in Duplicate) Date Issued *')Aplica+ion is hereby made to the Son Joaquin Local Health District for a permit to construct and install the work herein described. Co -,�49. This application is made in complianeywith o my Ordinance No., JOB ADDRESS AND LOCATION__.._ ----- --------- ------ �0 Phone-- 12�------- ------------ ---------- Owner's ------ - ---� 4- �� -------- -------------------------------- ------ ---------------- ------- ...d4 ----------- Phone------------ ---------------------- -------- --- Contractor's Name........... tl-- ------------ Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court t] Motel [-] Other,E] s. Lot size ---------- Number of living units: I... Number of bedrooms ... Number of bath -109 ........ Water Supply: Public system El Community system [:] Private In—Depth to Wafer Table ft. Character of soil to a depth of 3 fee+: Sand Ej Gravel Fj Sandy Loam El Clay Loam Clay Ej Adobe[] Hardpan C] Previous Application Made: Yes 0 No 2r New Construction: Yes E-'No El TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) 0 � ion__./A ---------- e Septic Tank: Distance from nearest weA_,�_e------Distanc2.from foundation_ -------------- No. of compartments....A . ...______._Capacity____! ��-c"'. -----------------Size_ V-C------Liquid depth------X Ar Disposal Field: Distance from nearest ell,�$-4�......Distance from foundaf191_/9---------Distance to nearest W hine i -Length of each ------ ------.Width of trench_ ------- N --------------4� dF I dr Number of lin( Type of filter A Depth of filter material----- ...... Total length Seepage Pit: Distance to nearest well..----------- --------Distance from foundation------------- ------Distance to nearest lot line______.._--______ ,; ❑ ine----------------- 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------------------------ :------.---- Distanceto nearest lot line---------------------------------- --------------------------------------------------------------------------------------------- --------------------------------------- Remodeling and/or repairing (describe):--------- -------- - --- -"-.-- ------------------------------- ------------------------------------------I------------------------------------------------------ -------------- ----------------------- -------- -------------- ------------------------ ------- --------..-------------------- ------------------------------------------------------ ------------------I----------------------------------------------------------------------- .... t ------------_--------------- ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- 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 He lfh District. -mn*6ur Contractor) ----------- (Signed)_-------------- By:-_---------------_---------------------------- ----------- --------------------------------(Title)-- (Plot plan, showing size of lot, location system in relation to wells, buildings, etc., can be placed on reverse sidef' SY FOR DEPARTMENT USE ONLY APPLICATIONACCEPTED BY-------------------- ...... ---- --------------- -- ---------------------------------------- DATE-------- -I/---------------------- ----------------------- REVIEWEDBY------------ ---------------- -'-'-'---- ----- - ----------------------------------------------------- DATE--------------• --------------------I-------------- --------- DATE---------------------- ------------_----------- - - ------ BUILDING PERMIT ISSUED ------------- ---------------- Alterations and/or recommendations:------ ----------------------------------------------------------------------------------------- ---------------------------------- ------------------------------------------- t----------------------------------------------------------------------------- ---------------------__------------------------ --------------------------------------------------------------------I I - ---------- ------------------------------- ----------------- ----------------------------------------------------------------------- ----------------------------------------------------------------------------- ------------------------------------------------------------------------------------------ ---------------------------------------------------- ---------------------- -------- ..... - ------------------------- ----- -------- ------- -------------------------- --------- ------- -------- ------- ------------------------- ------------------------ ---- ---- -------------7------------------------------- Z- __<- ---------------- Date---- ------------------- FINAL INSPECTION BY:...... ------------------ 44 A SAN JOAQUIN LOCAL HEALTH DISTRICT L 130 South American Street 300 WOO-Oak Sfre.ef. 132 Sycamore Street 814 Norfh "C" Street Stockton. California Lodi, California r w Manteca, California Tracy, California 145446 A7w00V