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APPLICATION FOR SANITATION PERMIT Permit No. G (Complete in Duplicate) Date Issued --------- - -- ---- AA' pplica+ion 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 nce No. 549. JOB ADDRESS ANp OCATION____ __Z _ _ A--------- ----"-_--_ Owner's Name-. -/- ------- ----------------- Phone' - --------------------- Address-----------41- -•-------- --- ------ - -----•------------------------•------- Contractor's Name----------------••--------------•-----------•- ----------------------------------------------------------------•-- -------------------- Phone------..-------------- Installation will serve: Residence` Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ 'Other ❑ Number of living units: --j-___ Number of bedrooms _ Number of baths ----I_ Lot size ----x_1-6.._0------.................. Water Supply: Public systemKI Community system ElPrivate C] Depth to Water Table -------- ft. Character of soil to a depth of 3 feet' Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe Hardpan ❑ Previous Application Made: Yes [:] No New Construction: Yes ❑ Nol { TYPE OF INSTALLATION AND SPECIFICATIONS: \ s (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Se tic Tank: Distance from nearest well_.;rl.rr� Distance from foundation-J-6------------M terial- ' No, of compartments-------:L.............Size---._j-_- `_ _._ ____Liquid depth.... ...............----Capacity* Dispos I Field: Distance from nearest we€!____..':I-tt.__D�stance from foundation---._/_. ______..Qistance to nearest lot liner-._________. Number of lines---.---�----.-.- ._ �il�engt,h,��off. each line--- ` .___.__..____-Width of trench � ---- ------------- Type of filter material ,� .d_S1.�tl filter material---_.�__. __{---.--.Total length-----1--Ra--------------------------- Seepage Pit: Distance to nearest well----------------------Distance from foundation------------------- Distance to nearest lot line----.------------ ❑ Number of pits----------------------Lining material----__---------------.-.Size:Diameter----r---__. _'-__-.Depth--------------------------------- Cesspool: Distance from nearest well---_-_---_--.._-Distance from foundation--------------------Lining material------_---_-_-_.---____-_-----__--. ❑ Size: Diameter------.,- -----------------------------Depth--------=--------------------- - - ------ -------Liquid Capacity---------------------------gals. Privy: Distance from nearest well............... -----------------------_----_,.-__Distance from nearest building----------------------------------------- 171 ._--._-___- ------._.__----__._-..-----_❑ Distance to nearest lot line------------------------------------------ ------------------------------------------------------------------------- Remodelingand/or repairing (descrilje).,-------- ---------------------------------------- ------------------•---•--•--•--• •--• -•-----•-------••--------..........---•------------ .. d ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- -----------------------------•--------------------------------------------------------------•-----------------------------------------------•--------------------------------------•-----------------•------•---------------- I hereby certify that I have prepared this application and that the workwill be done in accordance with San Joaquin County ordinances, State laws, and rules andiregalations of the San Joaquin Local Health District. (Signed) ---------- , -----------------•----- _------ {Owner and/or Contractor) By----------------------------------------------=--•---- ----------------------------------------------------------------------- - -----(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---------..'---------- - -- -- - --------- --------------------------------------- DATE --------------------------------- REVIEWEDBY----------------------------------- ------- ---- ----- ---- --------------------------------------------------- DATE-------- BUILDING PERMIT ISSUED---------------- = Alterations and/or recommendati ------------------------------------------- DATE------------------ ---- ons-- ---- - -- ----- ----------- -----------------------------------------------------------------•----••--- ------~ --- ---------- -----------•-----•---•---------------- '------------------ •-- --------------------------------------------------------- ----- •• -------------------------•------------------------ •-----........--------------------------------------- I ----------------------------------------------------= -- - -------------- ------ --------------------------------•-------------- ------ ( !S- FINAL - JI (Sl FINALINSPECTION BY:----- ---------------------------- Date.... ------------------------------------------------•---- 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 4 ES-'9-2M 145446 ATWODO 12-54