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I i� APPLICATION FOR SANITATION PERMIT Permit No. (Complete in Duplicate) Date Issued Aplica*lon is h6reby made to the San Joaquin Local Health District for a permit to construct and install the work herein described. This alLplication is made in compliance with County Ordinance No. 54 JOB ADDRESS AND /L T - -- ---- --------------------------------- N. ---------------- ------- ----------- .s Name Owner's Name --- ------------- --------------------------------------------- ---------------Phone.- Address_ -------/ - ---------- ---------- e----------------------------------------------------------••-•----------------------------.._.............. ---------- I----------- -----%-, Contractor s Name------------------------ ------------------------------------------------ Phone—, Installation will serve: Residence Apartment House E] Commercial 0 Trailer Court 0 'Motel ] Other L] Number of living units: --- Number of bedrooms __ ____ Number of baths Lot size Water Supply: Public system El Community system [] PrivateDepth ff '. eptto Water TablOr------- Character of soil to a depth of 3 feet: Sand Ej. Gravel E] Sandy ''Loam 0 Clay Loam El Clay ❑ Adob>k' Hardpan Ej Previous Application Made: I Yes E] NOX, New Construction: Yes if No F1 TYPE-OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available 'within 200 feet.) 4 eptic T tip,,,l F! Distance from Distance from nearesf-well-----------------Distance from f oundation--------------------Material----------------------------------- -------------- No. of compartments---------------------- ----Size------------------------------Liquid - depth--------------------------Capacity----------------------- -om nearesi well_________________Distance from foundation--------------------Distance to nearest lot line--__________---_- i Number of lines---------------------------_-------------------------Length of each line-------------_------------_--.Width of trench--------------------------- ------ Type rench- ------------------------- ------ Type of filter maferiaJ-------------------------Depthof filter material-----------------------Total length_____________________--____________--__._ Seepa' P, esf well___,��---------Distance fiOn fourrdafioni---1-d--------Di�tance to nearest lot line--__ 5777- 9 Distance to near Number of pits....../-------------Lining material,/....... _Size: Diameter-_2------- ---------Depth-----/5" ----------------- Cesspool: Distance from nearest well---___.__.__---_Distance from foundation------------------- Lining material------------------------------------- 171 Size: Diameter------------------ -------------------Depth----------------------------------------------------Liquid Capacity----------------------------gals. Privy: Distance 'from nearest well--------------------------------------------------Distance f om nearest building----------------------------------------- ElDisfaric6-fo'neares+ lot line---------------------------------------------------------- --- ----------=------------------------� Remodeling and/6r repairing (clespf,1e):------ - - -------I 45� ��---(�------------- ----------- ---- ------ ........ .. .............. ...... ---------- ------- ------- ------------ ---------/ ------------------------------------------------------ .7 0.1, --- -------------- ---------------------------------*-------------------------*------------------------------------- -------- ------ ---------- -------- ----------------- ------------------------ -------------------------------- -------------------------------------------------------------------------------------- OV I hereby cer'tif 'y that I -aye prepared fhi4'pplication and that the work will be done in accordance with San Joaquin County ordinances, StateAaw's ay"ules and regula(fions of the San Joaquin Local Health District. (Signed)-------- 7 ----(Owner and/or Contractor) ------------------- --------------------------------------------------------- --- ------I------------------------- By:---------------------------- ----------------------------------------- -------------- --(Title)------ (Plot plan, showing size of lot, location of i(ysferri in relation to wells; buildings, etc., can be pirced n4reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY---- ----------------- ------------------------------------ <1 REVIEWED BY.-------------------------------- ----------------------- -��.: ;!_:-:------------------------------------------------- DATE--------- ......... 4 --------- DATE--- -------------- BUILDING PERMIT ISSUED----------------------------I DATE-------------- -- --------------------------- Alterations and/or recommendations:----- -------- - --------------------------- --------------------------------!% -------- ----------------- ------------------------------------------------ --- 7--- ---------------------------------------------------------------- ----------- --------------- 7- -------------------- -------- ----- ------------------------------------- ------------------------------------------------------ ----------- ------------ -- –---- -- -E�_ ------------------------ ----------------------------------------------------------------------------------------------------------------------------------------------------------- ---------------------------------- ---------------- ------------------------------------------I-------------------------------------------- -------------------------------. ------------------------------------------------ --------------------------------------------- FINAL INSPECTION BY:---- ---------I-------------------- Date------- _ a SAN ate-------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Street 014 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California ES-9-2M ; . Revised W-2100