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APPLICATION FOR SANITATION PERMIT Permit No. -A-- .;.7_-,7 ------- - (Complete in Duplicate) dy ---W Date Issue • Application is her?e/by'12% 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. 54 JOB ADDRESS ND LOCATION--- ---- -- ---- ------ --- ------------------------------------------------------------------------------- Owner's Nn� -•--- --- --------------------------------------------------------------------- Phone-------—----------------------- ---------- Address..--.---------- ---- i- Contractor's Name---- ---------------------- _/--- - -- - --------------------------- Phone------------------------ Installation ------------------------------ Phone---------------------------------- Installation will serve: Residence Apartment House E] Commercial F] Trailer Court E] (.W f I/[] Other Number of living 09" units: --- Number of bedrooms ---Z_ Numb baths ---/--- Lot size -- ------ -------------------------------------------- Water Supply: Public system ❑ Community system El Private Number to Wafer Table -------- ft. Character of soil to a depth of 3 feet: Sand F-1 Gravel E] Sandy L Clay Loam E] Clay E] Adobe 2"'Hrdpan E] Previous Application Made: Yes E] No 2?r"71\1ew Construction: Yes o;��No El TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Se nk: Distance from nearest well---'5-0-------Distancp from foundation----1-0-1--------Material--_!0e-1jW0_6W_____ No. of compartments--------0—-------------- -------Liquid depth------1,4...............Capacity---eO Dis Field: Distance from nearest well-.4b.__-__.Distance from foundation----10-----------Distance to nearest lot line-----Z -',------ p;r Number of lines------IV--------------- ---------Length of each line/tP, Width of trench------L-------------------------- Type of filter maferial&��Ik---------Depth of filter material----- Total length------- _________________________ Seepage Pit: Distance to nearest well----------------------Distance from foundation--,-------_-------Distance to nearest lot line_________________ ❑ ine----------------- 0 Number of pits----------------------Lining material-----------------------Size: Diameter_---------------------_Depth_-------------------------------- - Cesspool: Distance from nearest well_________________Distance from foundation------------------- Lining material-______________________,_____________- El Size: Diameter----------------------------------- --Depth----------------------------------------------------Liquid Capacity----- :--- ------- Privy: Distance from nearest well------------------------------------------------Distance from nearest building_______________-_-_-----_________________. Distance to nearest lot line--------------------------------------------------------------------------------------- Remodeling and/or repairing (describe):.-------#41A___ ------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- -------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- N . I ---------1-------------------------------- ---------------------------------------------------------------------------------.----------------------------:----------------------------------------------------------- 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)- -- - ------------- ----------------------------------------------(Owner and/or Contractor) % ------------------------------------------------------------(Title)---------------------------------------------------------------- 4-------------------------------------- 6�/y-------- - ------- --------- _4 system in relation to Wells, buildings, etc., can be placed on reverse side). (Plot plan, showing size of lot, location of FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY--------- --------------------------------------- DATE-----6 _? _4 REVIEWEDBY--------------------------------------------- --------" ----------------------------------------------------------------- DATE--------- . BUILDING ATE----------- BUILDING PERMIT ISSUED-------------- ---------- D I-- -- ----------------------------------------- -------------- ------------ ions:----------��Akb -------Q_� Alterations an or re " endati P44A---- -----�L A ------- A------- ----t--L4JL-;-----------------------------------------------------------------------------------------------------------------------------_--------------_------------ ------------- -------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- --------------------------I-------------------------------------------------------------------------------------------------------------------------I------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------ --------------------------------------------------------------------------------------------------------------------------- FINAL INSPECTION BY-------- -- -----k"164---—----------------------- Date-------------- ----- ------Z �,----------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Street 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California ES-9-2M 8-51 Revised W-2100