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APPLICATION FOR SANITATION PERMIT Permit No. v --------------- (Complete in Duplicate) f— . 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 compliance with County Ordinance No. SS49. JOB ADDRESS A LOCA7�lON `- ------------------------ 11.1i r — ---- s - - P -f ------- Owner's Name Address.-_0_0----- --`------- -------- ------ --------------------------'----------------------------------------------------------------- Contractor's Name_. --- -------- - --- Prone Installation will serve: Residence ❑ Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel�❑ Other Pel! Number of living units: _____Number of bedrooms -------- Number of baths -------- Lot size ____CVP - _•_---_�__-_0_I_ ------------------- 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 [:1 Clay Adobe ❑ Hardpan ❑ Previous Application Made: Yes ❑ No W New Construction: Yes e No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) � r - 1-0 I Septic ank: Distance from nearest weil--="•`__-7; _Dista%q fr ,%Urogtion----- ______-Mater a---__,__-_-- --•-_ ________- No. of compartments---------------- ----- Liquid depth }____-- ---------__ p Y---..- �. _ size_C�_�_ `J�_ Ca acit Disposal Field: Distance from nearest well._ '"____ __Distance from foundation___ __ Distance to nearest lot lir:�e/-�� __...._ Number of lines------- _ ___�_r-Length of each line_________--� Width of trench__-_____0;? ° :'"_______________ Type of filter materi ! Depth of filter material________ _ _ _____Total length_________ _ _______________________ Seepage Pit: Distance to nearest well----------- ---------Distance from foundation___________-_--___.Distance to nearest lot line----------------- ElNumber of pits----------------------Lining material----------------------Size: Diameter------------------------Dept'h_---------- ,.----------------_:_ Cesspool: Distance from nearest wef!-----------------Distance from foundation_._.__ ------------Lining material________________-______-____________. ❑ Size: Diameter--------------------------------------Depth----------------------------------------------------Liquid Capacity----------------------------gals. Privy: Distance from nearest well-__-_._-________________________________________Distance from nearest building_-_ -----_--___--.-________-_-_-_------ ❑ Distance to nearest lot line- ----------------------------------------------------------------------------------------------------- Remodelingand/or repairing (describe):------------------------------------------------------------------------------------------------------------------------------------------------------ -------------------------------•---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ----------------------- ------ - - -- ----------------------•------------------------------------------------------------------------------------- --------------------------------------------------------------------------------------------------------------- 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. (Signed) 1 - "-------------------- (Owner and/or Contractor) ------------------------------------ B (Title)_ ------------------------ --------------------------------------------------------------- (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 s APPLICATIONACCEPTED BY-- --- - ------------------ ------------=-------------------------------------------------- DATE--�------------------------------------ ----------- REVIEWEDBY-------------- ------ --------�' __�__._------------------------------- --------------------------------.------------_ DATE--- BUILDING PERMIT 155UEi} DATE ----------------------------------- Alterations and/or recommendations---------------------- --------------------------------------------------------------------------------------- ---- --------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------- - ------------------------------------------ ---------------------------------------------------------------A-------------------------------- ------------------------------------------------------------------------------------------------------------------- - - ---------------------------------------------- -------------- ----------------------------------------------------- ------------------------------------------------------------------•-- ------------------------------------------ WAL 'INSPECTION BY _ Date --r - ------------------------------------------------------------ SAN ------- -----SAN JOAQUIN LOCAL HEALTH DISTRICT 130 Soufk American Street 300 West Oak Street 132 Sycamore Street 814 Norfk "C" Sfreef Stockton, California Lodi, California Manteca, California Tracy, California ES---9•--2 W.8-5 I'Revised W-2100