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I APPLICATION FOR SANITATION PERMIT Permit No. ..- -. .��-��- S (Complete in Duplicate) Date Issued Applica}ion is hereby made to the Sari 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 LOC TION--- 1.�------------ Q----- - - -------------- ---------- -----------------------I------------ --- Phone----•------------------------------- Owner s ame-- ' Address ------------•-------------•------------••------------------------------------------------------------------- ------ ----------------------- _ ------------ Phon� --- --- ---6------ Contractor's Name.. ------------' � r� Ins+allation will serve: Residence ar ment House F1Commercial ❑ Trailer Court ❑ Motel [3 Other [I Number of living units: _(___ Number of bedrooms _ .- Number of baths _ ____ Lot size ____- .- ----- - --? ----------------•- Water Supply: Public system A--6emmunity system ❑ Private ❑ Depth to Water Tabled-- ft. Character of soil to a depth of 3 feet: Sand E] Gravel ❑ Sandy Loam [I Clay Loam ❑ Clay ❑ Adobe ardpan ❑ Previous Application Made: Yes ❑ No Er ew Construction: Yes ❑ No TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) epti Tank Distance from nearest well -_--_Distance from foundation--------------------Material_._ _.:.__._.___ __.__________.________.__.__. No. of compartments-------------- ----- -----Size-----•-------------------------Liquid depth-------------------------Capacity----------------------- .�--0..Distance to nearest lot isposal Field: Distance from nearest weII,, i�^.-'f.--Distance from foundation.__ Width of trench.Zq_r'_______________ �-� g �Q . Number of lines---------�.___..__ . _ Length of each line---- Type of filter material---- i--. __- Depth of filter material--_---100.`=_---.Total length----_4_0--- from - �C!-- ----------------•---- 5eepage Pit: Distance to nearest well__________ _________Distance from foundation-------------------- to nearest lot line_-.__._.-__-_---- ❑ ---------Depth of pits----------------------Li�ing material:----------------- Diameter----------.-- ----- --- Y p Distance from foundation:-,--.:-_._.'ry--_..Lining material------------------------------------- i nce from ----------------- Cesspool: Size:Diameter nearest well----- ----------Depth-..___._____:_----- --------=------- --- - --------Liquid Capacity.-------- gals. , Distance from nearest well_ ..___..____----------------------------- ---Distance from nearest building------------------------------------------ Privy: -•------------------------------- ❑ Distance to nearest lot line--------- --- ---- ----------••-------- r _ Remodelin nd/or r pairing (deseribej:_. -%A---- ------------ �( P Y ----------y _ _. ------------------------------------------------- ------------------ _/pry ' - r -- -- 1 '- 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. --------- (0--at and�Con+ract (Signed)--- ------------------- ---------- ------ --------------------------------------------(Title)------------------------------------------------------- By:--------- - (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). ! FOR DEPARTMENT USE ONLY 1 DATE-- ----- ------------------------------------------ APPLICATION ACCEPTED BY--------------------- -- ----------�_ REVIEWEb BY_ --- DATE--------------------- ------------------------- ---- ------------------------ BUILDING PERMIT ISSUED-------------------------- DATE----.--------••----- -- ---- ----- ---- ------ Alterations and/or recommendations:--------------------- --- -- ---- ----------- --------------------------------------- --------------•-----------•------ ;:---- ----------------------------------------------------------- Date---------------•----- FINAL INSPECTION BY:...__----_.-_--__-_-._ = ---- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Street 814 North "C" Street Stock+on, California Lodi, California Manteca, California Tracy, California f Fg 9-2M 145446 ATWODO 12-54 _