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Permit No --------- APPLICATION FOR SANITATION PERMIT (Complete in Duplicate) Date Issued Application is harebade 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 O dinance No. 542. • ----•------------------------ ------ ------ JOB ---- ------ JOB ADDRESS LOCATI to &4_7-- - --- ------ ----- -- --- •----- ---------- --------•------------ . _ . Phone_Z----�. Owner's Name----- ---- -- ------------•------•- - --------------------------------------------------- ---------•---------------------------------- Address ------------- EPhone----------------------------------- Contractor's Name---- ._. - ---"-----"----- ------ Installation will serve: ' Residence Apartment House ❑ Commercial ❑ Trainer Court ❑ Mootpl E�t Number of living units: umber of bedrooms ___Number of baths .- I --- Lot size ---- --- - -------------------------- __. __ _ _. Water Supply: Public system Community system ❑ 'Private❑-`Depth-to,Water Table __ ft. Character of soil to a depth of 3 fee : Sand E] Gravel ❑ Sandy Loam Clay Loam El Clay El Adobe[Hardpan E]Previous Application Made: Yes fee ❑ New Construction: Yes No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: r (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tank: Distance from nearest well_________________Distance from foundation-----------------."Materia___________"_____._______ _------------------ ❑ No. of compartments--------------------------Size---------------------------------once from foundation__--_________.____.Liquid depth-------------------------Capacity--------- ------ ------ ___DistDistance to nearest lot line----------------- Disposal Field: Distance from nearest well_______________ a , Number of iiries Length-of each line--------"--------------------Width of trench ❑ -----------Total length----------------------------------------- Type of fiiter4material_________________________Depth of filter material___"___.__- Seepage Pit: Distance to nearest well----------------------Distance from foundation--------------------Distance to nearest lot line----------------- ❑ ---------- Number of pits------------------ -Lining terial-----------------------Size: Diameter___-•__-- --"-__-Deptn -�istance from fo ndation__ ._ -__.---___.. min material__ __ __ ---- 1 ---------------Li Liquid Capacity ------gals. Cessp L•� Distance from neare�„�P+ell__�„� "-- � � g � 71 Size': Diameter-------�--- ----------.Depth_ q p Y Privy: Distance from nearest well-__.___________________"-- -Distance from nearest building--------------------------------------- - ❑""""""""'""'"'Di�s`tance to n"Barest"lot"line-- ---- ----- ---------------------------------------------------- - ----------- ----- --------------------------------------- R*ocland bT, e airin describ g /{ p 9 ------ ------------------- -------------- --------- ------- ►s� --------- �Q�,,, �`"_ ---------- --------------------------------- -------•--------------------------•- -------------- '--------------- ---------------------------------------------------------------------•---------------------------•--------------------------------- -------------- ! heeeb)(certify that-1-rhave Iprepared.this.application-and.that the wark will,be-done-in-accordance with San Joaquin County ordinances, State'llaws;_and rules and regulations of the San Joaquin Locel Health District. I 5i ned __--------------------------------- (Owner and/or Contractor] ( 9 f -= ion A ---------------------(Title}----------c------- ------- --- . B)------------------- (Plo# plan; howing size of lot; location of s,lystemi"n relation to wells buildings, etc.,�can be placed on reverse side}. FOR DEPARTMENT USE`ONLY # APPLICATION ACCEIPTED BY------------- ------------------ --- --- DATE REVIEWED BY-----------=--"---------------------------- ----------- ------------ DATE-------------- BUILDING PERMIT ISSUED--------------------------------- -------------- -------------------- ----------------_- DATE-------------------°------ --------------------------------- ----------------- - '�"' Alterations and/or redommendations:-_--�-�-------�.__::--- ------------------ -A` _ ="'•- ------------------------------------------------------------------------------------ --•-------•-----------------}---------------------------------- ---------- --- ----------------------------- ` ----- - -- ---------------------------- FINAL INSPECTION BY:-----.:- ` Date------------- ------- -- - k SAN JOAQ,UIN LOCAL HEALTH DISTRICT 300 West Oak Street K e sj 132 Sycamore Street 814 North "C" Street 130 South American Street 1 '�• Trac California Stockton, California I Lodi, California Manteca, California Y E5-9-2M 10-52 Revised W-2100