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APPLICATION FOR SANITATION PERMIT Permit No. (Complete in Duplicate) Date Issued Application is herebymade 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 ',r�finance No 549 JOB ADDRESS A CA 10 $'y --------e--------------------------------- A� ........................ Owner's NaTe----------------------------------- - ----- ----- - --- ------- Address---- ------------------ --0--------------------------------------- Phoney_ -------------- *--91- ----------- -----------------------------------------I---------------------------------------------------------------------------- Contractor's Name--- -------------- --- ------------------------------------------------------------------ ----------------------------------- Phone Installation will serve: Residence Ej Apartment House El Commercial railer Court E] Motel E] Other E] Number of living units: -------- umber of bedrooms -------- Number of baths_--___ Lot size Wafer Supply: Public system Community system E] Private E] Depth to Water Table -------- ft. Character of soil to a depth of 3 feet: Sand El Gravel E] Sandy Loam U,� Clay Loam E] Clay E]. Adobe �ardpan-E] Previous Application Made: Yes Ej No Z New Construction: Yes /No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet. I Septic Tank: Distance from nearest well DisfancA fror_, four fion-1 - ,a --.Maf rial----- ----------------- No. of compartments------------ ------- Li q u i d -d--e--p--t--h--------- ----------------- apacify---- Disposal Field: Distance from nearest well_________________Distance from'rom foundation--------------------Distance to nearest lot line________---- ❑ Number of lines-----------------------------------Length of each line-----------=-----------------Width of french ------------- Type of filter material-------------------------Depth of filter material-----------------------Total length___----------------------------_-__ Seepa a ength-----------------------------------Seepa,ePj :. Distance to nearest well------------------- ---Distance from foundation--------------------Distance to nearest lot line__________---____ ❑ Number of pits----------------------Lining material--------------- ------Size: Diameter-----------------------Depth--------------------------------- Cesspool: Distance from nearest weft______________ Distance from foundation--------------------Lining material___-_-____________--_- ------------- -- ❑ Size: Diameter_-- ______-_ Depth---------------------------- ----------------------Liquid Capacity---------------------- - --------qa1s Privy: Distance from nearest' --------------Distance from nearest building------------ ----------------- 0 Distance to nearest lot line --------------------- Remodeling and/or repairing (describ'e):------------------------------------------- ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------•----------------------------------- --- ----------------------I-------------------------------------------I------I------------------------------------------------------------------------------------------------------------------------------------------------ I hereby certify that I 6ve pre4red this application and that the work will be done in accordance with San Joaquin Coujjn ordinances, State laws, and rules andregi afions of the San Joaquin Local Health District. (Signed) ------ I -—-----------------------------------------------------------------Z--------------------------(Owner and/or Contractor) ------------------------------------ ------------------------------------------------------------------------------------------------(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--_-__ 1 --------------------------------------------------------------------------------- DATE REVIE ---- ---IZ--- WED BY -------------------------------------------- ---- --- - ----------------------------------------------------------------------------- DATE - ------------------------------------------- BUILDING PERMIT ISSUED------------------------------------------ --------------- - ------- ------------------------------ DATE---------------- Altera ons and/or recomenericlations: ------------------------ ---------------4------ ---- ------------------------------I-------- ---------------------------------------------------------------------------- -------- ---------------------------I---------------------------------- 41-AvWou- ------------ -- ----------------------------------------------------------------I---------------------------------V----------:-------- ------------------------------------------------------------------------------------------------------ --------------I----------------- ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------ -------------------------------------- ------------------------------------------------------------------------------------------------------------- FINAL INSPECTION BY- _0 Date-------- -C'..:� ------- - ------------------------ I SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Street 814 North "C" Street Stockton, California Lo.di, California Manteca, California Tracy, California ES-9-2M 8-51 Revised W-iloo