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APPLICATION FOR SANITATION PERMIT Permit No. 0.��k ---.--- ' (Complete in Duplicate) Date j Issued _--.- _- ' � A lication is herebymade to the San Joaquin Local Health District for a permit to co t uct and install the work he ern escr' ed. This lication.ris ;mde in complia ne with y Or nage N�1 JOB ADDRESS LOCA N---- -- ------ -- --------- �---- Phone--- = Owner's Name-- --- ---.- ---------------------- ------------------------------ ---- - ----- -------- Address---- -. ------------•------------ �- ----------- Phone--------------------- Contractor's Name--------------------�---- ----------------- ------------------------------------ ---- f Installation will serve: Residence Apartment House ❑r ! Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: _- _ Number of bedrooms _4 Number of baths - __ Lot size -----1-tl ----------- ----------- Water Supply: Public system ❑ Community system ❑ Private [vep#h to Water Table ____ -_ ft. Character of soil to a depth of 3 feet: Sand Gravel [3 ' Sandy{Loam Clay Loam El Clay El Adobe ❑ Hardpan E]Previous Application Made: Yes ❑ No New Construction: Yes No ❑ ' i TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) ,� z Septic ank: Distance from nearest well Distance foundation ndation-_ ,Matana------- --------------- / ^� - C - ` r . No. of compartments--------- Z ----Size------ -- ----x - Liquid - -.-___-bisancefrofoundation ! Dto nearest lot lin disDistance from nearest � - - ------------- P - --- ---r- ---- Width of trench.-------- ------------- Number of lines------- ---------Length of each line------------ ------ ------- .----_---Total length---.--_.rt__ -..--_:---_-------- filter maType of ter, De th offilter materia „ Seepage Pit: Distance to nearest well ---------------------Distance from foundation__-._---__-___----. Number os---------------------- Distance to nearest lot line-- dbf pitLining material-------------- --------Size: Diameter-------------- --------.Depth-------------- -- 11------ ❑ ---- Cesspool: Distance from nearest well-----------------Distance from foundation.-=-------_----___.Lining material-_---__---.------__-:-.----.. ----- ❑ Size: Diameter--------------------------t----------Death--------------------- --- - -Liquid Capacity------------------- 1I-------gals. Distance from nearest building �I . Privy: distance from nearest ural!------- --------------------------------------- g------------- ----------�--------------- El ----- ------ ❑ Distance to nearest lot line----- ------------------------- ------------------------ ---------- ------------ - ------------------------------------ Rem ling and/ar e airin describe . --------------- ----------------------- ' - --------------•-------------- ---- -- ----- - ' -------- -- ----- --- - - ------ - •-_ - .. ..-Y"fir -- -- -- - .___ - f - •__F�_ _: f ' - - h -.------ -- ---- ----•-- - ---- P�-. --- ----------------------------------------- II _y l hereby certify that I have prepared this ap licati nand that the work will be done in accordance with San Joaquin County ordinances, State laws, and rules and regulation's of the San Joaquin Local Health District. p ►. (Signed).----a---C �p1 - _ ----- .-------. caner and/or Contractor) , --------------------------------- ---------------------------------------------------------(Title)------------------------------------------------ --------------- (Plot -------------(Plot pian, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). �I FOR DEPARTMENT USE ONLY � )� APPLICATION ACCEPTED BY- --------------------------------- --------------- ----------------------------------------- DATE, -------------- -------------------==11---- -- ---- DATE_— -------•---------------------------------•------- REVIEWEDBY------------- ------------------- -- --- --------------=---------------------- ------------------------ it BUILDINGPERMIT ISSUED--------------- -------- ---------------'-•------------ DATE-- -�L„-.,--.------------------------------;------------- -----•------------------------- '!--------------- Alterations and/or recommendations:----------------- ----------------- --------------------------------------------------------------------- -. ii j ...-------------------------'--•---------•------. _...-----'.--._._-----__-•- ----.. ----------------------- ------------------------------_---.-------- ------- Date ------ ! - ------- FINAL INSPECTION SY:__ -- ---- ;,// -------------------------------------------- Dt � II SAN JOAQUIN LOCAL HEALTH DISTRICT fA 130 South American Street 300 West Oak Street 132 Sycamore Street . 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California, it I ES-4-2M 10-52 Revised W-2100 - --