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APPLICATION FOR SANITATION PERMIT Permit No. ..1.?� `� »• (Complete in Duplicate( Date Issued ..fh.y� . This Permit Expires 1 Year From Date Issued A pplication is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described. +w This application is made in compliance with County Ordinance o. 5 9. .. JOB ADDRESS ANDOCATIO 1�... ------ Owner's ................. Owner's Name.._ ............ . Phone....................... _._.__.. Address...........,17.7..... c7•. ,� -.L ...,.... .................. .............................................. ...».. Contractor's Name .................................................._................................... Phone........................ _ • Installation will serve: Residence ❑ Apartment House ❑ Commercial ❑ Trailer Court [7 Motel ❑ Other ®--� Number of living units: . Number of bedrooms........ Number of baths .,2e Lot size S1...JUI—W. .................. Water Supply: Public system ❑ Community system ❑ Private ❑ Depth to Wator Table . ... ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel❑ Sandy Loam Clay Loam❑ Clay❑ Adobe❑ Hardpan❑ Previous Application Made: Yes ❑ No ❑ New Construction: Yes ❑ No ❑ FHANA:Yes❑ No❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 het.) Septic Tank: Distance from nearest well.....DisfancyL from foundation...l�........ aterial.. ... (A� t4o. of compartfnents.. ..�a._...._....Size.vfo– .......Liquid dep�h..� �... .... .. .Cepaeity... .. .•. Di,nosal Feld- Distance r-om nearest well .......Distance from foundatio ..... Distance to nearest .ot line.. a� .... l� .............. Number of ;Ines .. ...... .. ength of each line... �... .f♦ Width of tref:!,... �� '...........» Type of f ltc, material..�y.44tCopth of filter mato'at.....� ...,....Total length......(/.v...............»......... Seepo it: Distance to nearest well ........... .......Distance from foundation..................Distance to nearest lot line................ Number of pitsg a .........Linin material...................... Site: Diameter........ .. .. Depth. Cesspool. Distance from nearest well.................Distance from foundation.............. Lining material..................................... ❑ S;zc: Diameter ..Depfh....... ..................... ...............Liquid CePcu'li ....................»-gels. C1 Privy: Distance from nearest well-..........I.......:............ ... ........Distance from nearest building.. ...................................... ❑ Distance to nearest lot line ............................ .. .. ..—... ................... ..... . ......... ....................... oe 01, Remodeling and/or repairing _ser uo) ... ».... .. .».......»................»................... _»».»....._... !..................................................... ....... . ...... . ............... .. .. . _ .................... ....................................................................................»...»................................ . .........._................... . ......................................................................................................__...... I herobY 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).. ....... {Qrlr Contractor) By:.......... ...................... ......... (Plot plan, showing site of lot, location of system relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY ......... DATE....... REVIEWEDBY. .. .... . .........:........................................................... DATE........................................................... BUILDINGPERMIT ISSUED . .................................. ".»».»......................... DATE............................................................ Alterationsand/or recommendations: . .. . .. ...... ......................_......».............................................................................................. _. .......... ...................».................................................................................................. ......... ....... ....... . .. ... .. .......................................................... . . . _......._..................... ................. ............. .............................. ..... ............................................. ............................... .. ... ......................... (�/ ^ .�0..� 3.-6a. .......... ............. Date.... FINAL INSPECTIOrf.9y/ ir� �1 SAN JOAQUIN LOCAL HEALTH DISTRICT Ila SouA American Street 300 Wast Oak Stroaf 132 Sycamore Stn►ef 814 Nora. "C"SOW Sfockton, Ca Jom;a Lodi, California Maafaea. CalifeMta Tracy. California •