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APPLICATION FOR SANITATION PERMIT Permit Na. (Complete in Duplicate) 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. 549. Ire JOB ADDRESS AND LOC PAION- tit Phone. --- ----------- Owner's Name_ —---------------------------------------------------------------------------------------------- Ph Address---------------- ------------------------------I------------ Phone----------------------------------- Contractor's Name---------- ------------I--------------------------------------------------- Installation will serve: Residence Apartment House E] Commercial [] Trailer Court ❑ Motel ❑ Other El Number of living units: __ Number of bedrooms -------- Number-of baths j---- Lot size ------------------------ - Water Supply: Public system 11 Community system El Private 94 Depth to Wafer Table -------- ft. Character of soil to a depth of 3 feet: Sand E] Gravel F-1 Sandy Loam El Clay Loam El Clay El Adobe Hardpan El. Previous Application Made: Yes V No 0 New Construction: Yes X No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tank- Distance from nearest well--"C O-"--_-Distance from foundation-- 1#4--------Material----_--_ -- - -- ---------------- No. of compartments-------!)��------------Size----- F-K-4-------------Liquid depth------ I'l(--------------- apelcify-----r-------- W, fr nearest lot line___.Jr_ Disposal Field: Distance from nearest well___ _10------Distance from foundation--_-.d 0---------Distance to nc '- Disposal Length of each line ____--.Width of trench----------1�..................... Number of lines--4 I -----------AkPi- Type of filter ma ---Depth of filter material--------18...........Total length---------1&0----------------------- ----------------- Seepage Pit: Distance to nearest well------------- --------Distance from foundation--------------------Distance to nearest lot line Number of pits----------------------Lining material----------_"-----------Size: Diameter---------- ------------Depth-------------------------7------ ❑ Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material.__---_._---------------- --- a, Size: Diameter"""-___.______"- Depth----I-----------------------------------------------Liquid Capacity-------------------------•-9 )1. El P Distance from nearest building-----_--to --------I------------1- . Privy- Distance from nearest well"---------------/0-16"P------------------- -- -------------- IL Distance to nearest lot line------------------%>------------- -------------------------- ------ ------------- ------------------------------------- ------------------------------------------------- Remodeling and/or repairing (describe):-------------- ---&6Aj---------------------------------------------------------------- --------------------------------I------- --------------------------------I------------------------------------ ------------------------------------------------------------------------------------------I----------------- -------I----------...------------------------------------ ---------------------------------I-----------------------------------------I-----------------------------------------------------I--------------- --------------------------------------------------------------------------------------------------------- . I---------------------------------------------------------------------------------------------- --------- 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. � ------------------------(Owner and/or Contractor} [Signed)--------17�L-- ----- ----- ---- ------------------------------------------ io-4 (Title)-------------------------------------------------------------- - By:_------ - ------ ---V -------------------------------(Title) plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on.reverse side). and/or C 0 n t Fa 1_1orl FOR DEPARTMENT USE ONLY' .......... .... ..... ......... APPLICATION ACCEPTED BY--------"_"------�jj' -------------------------------------------------- --- DATE---- - ------------- ---- BY.----------------------------------- ------------------------------------------------- DATE rte--------------- DATE-------------------------------- BUILDING PERMIT ISSUED---------------------------7—-— "% .. Alterations and/or rec;��mmen �aifio_ lls:--- ------------- ---------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------- ------------------------------------------------- ----------- ------------ -------i? S7--------- -------------------------------------- ---7 --------------------------- ----------------------------------------- --------------------------------- --- -----------r,�----------------------------------------------- - -------------- ------------- ----------------- -------------------- ---------------------------------------------------am.0 WAMWA-------------------------WNW-WAR---------------------------------------------------- -------------------------------------I-------------------------------------------------------------------------- -------------------------- --------------------------------------------------------------------------------- FINAL INSPECTION BY:"."--------------- -------- ---------- ----- -- ------- Date------------------------------------------------------------------------------ SAN JOAQUIN LOCAL HEALTH DISTRICT 132 S 130 South American Street 300 West Oak Street ycamore Street 814 North "C" Street Stockton. California Lodi, California Manteca, California Tracy, Califofh4 ES-9-2M B-51 Revised W-2100