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APPLICATION FOR SANITATION PERMIT Permit No. (Complete in Duplicate) Date Issued Application is hereby made to the San Joaquin Local Health Distric-t for a permit-fo construct and install the work herein described. This application is made in compliance Y41—cou n fy Ord!,nance No 54_SJlcL A A qq r JOB ADDRESS ANLOCATIO 4 Owner's Name______----q ----- ---------------- ----------------------------------------- Phone------------------------------------ Address ---------- -4 ---------------------------- ------------------------------------------------------------ Contractor's Name------------ --------------------------------------------------------------------------------- ---------------- Phone----------------------------------- Installation will serve: Residence 0 Apartment House F] Commercial E] Trailer C*_ar* 10/Mo0 Other F1 Number of living units. ___1---- Number of bedrooms -------- Number of baths -------- Lot sizeUrvE- ----------------------------------- Water Supply: Public system E] Community system D Private © Depth to Water Table ft. - Character of soil to a depth of 3 feet: Sa,nd E] Gravel E] Sandy Loam 0 - Clay Loam E] Clay [] Adobe'[D/Hardpan El Ej Previous Application Made: Yes ❑ No New Construction: Yes E51"No E] FHA/VA: Yes F7 No El TYPE OF INSTALLATION AND SPECIFICATIONS: I , (No septic tank or cesspool permitted if public fewer ewer is available within 200 feet.) SepticTank: Distance from nearest well---16—ro----Distance fromrfoun F daf ion------1-0--------M*ae jji a I No. of compartments------- -a_------- Size_, N.S.-X-3---------Liquid depth---------- ----------------Capacity--_- Dis p Field: Distance from nearest well_._; -----Distance from foundation --------Distance to nearest lot line 1_15.e Z .21 -_ Number of lines___------- Length of each line_______ eb-, Width of french._ —- 8 y -%-(---------------------- Type of filter material -Depth of filter material___.__I_ ____________Total length---------K6 -------------------------- Seepage Pit: Distance to nearest well----------------------Distance from foundation-------------__.Disfance to nearest lot iine----------------- F1 Number of pits----------------------Lining material----_---------------- Size: Diameter------------------ ----Depth--------------------------------- Cesspool: Distance from nearest well-----------------Distance from foundation___________________.Lining material________._.-___---------.___________. ❑ Size: aterial-------------------------------------- Size: Diameter---------------------------------------Depth----------------------------------------------------Liquid Capacity----------------------------9a Privy: Distance from rearest well____________________________ - ----------Distance from nearest building----- ----------------------------------N� El Distance to nearest lot line-, -- ------------------------------------------------------------k--------------------------------------------------------------------------------------- Remodebing nd/orj�iepa-irijncj (de,�C 'be]:lb e), ------T — ----- --- ---------- -—------ _P 41 r --- ---- ---- - --- - ------ 7 - -- -- --------- - -- ------------- ------- -- ---- - -- --- ---------------------- ---- ------------- -- --------------------------------------------------------- ---------------------------------------------------------------------------------------------------------------------------------- ---- 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. (Signed)-- --- --------------------------------- ------------------------------------I--------------------------------------(Owner and/or Contractor) Al"40"7----------------------------------------------- By:-----------------------•----•------•----------------------------------------- (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 APPLICATION ACCEPTED BY------------- ----- -- -- - ---- -- ---------------------------------------- DATE---------------- REVIEWEDBY------------------------------------- --------- ------------------------ --------------------------------- -------------- - ------------------- DATE------t BUILDING PERMIT ISSUED----------------------------------------------------------- - ------- ------------------ DATE.---------- --------- --------------------- Alterations and/or recommendations:----------------------- ---------------------------------------------------------------------------------------------- ------------------ ------------ --------- ------------------------------------------------------------------------------------I--------------------------------------------------- ----------------------------- ------------------- ------- -------------------------------------------------------------------------------------------------------11------------ ----------------------------------- --- ------------------------------ ----- --------- ------------------------------------------------------------------------------------------------------------------------- ------------------------------ ----------------- - --- - --- --------------- - ------ - -- ---- -- ---------------------------------------------- ---------------------------------- ---------------------------- FINAL INSPECTI -------- Date........ 0 SAN JOAQUIN LOCAL HEALTH DiST'RICT, 130 South American Street 300 West Oak SIreet 132 Sycamore Street 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California ES-9-2M Reviseci 1,57 F.P.CO.