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APPLICATION FOR SANITATION PERMIT Permit No. ---------- (Complete in Duplicate) Date Issued1110�04W Application 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 Ordinance No. 544. ; .. ------ JOB ADDRESS AND LOCATION______..____�__ -----_=--`------ ----��-- ---- ' y ._ - Owners Name ---�4 ------ -- - - ----------------- ------------------------------ Address ---------------------------------------------------- ------------------------- - ------------- --------- --- Contractor's Name------------------- --------- -- -- ----: ------------ ---------- ------------------------- ------ -- Phone---------------------------------- i Installation will serve: Residence 91--A}5artment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ e`�` - Number of living units: /-____- Number of bedroomsy�Number of baths Lot size _--________.__--_____- Water Supply: Public systemommunity system fl Private ❑ Depth to Water Table -------- ft. § Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ AdobeQ-jzlardpan Previous Application Made: Yes ❑ No Construction: Yes 21. -0 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 Distance from foundation /_________. ---.Material--------��"�--------- ---------------- • _Ca acit No. of compartments----------- �- ---Size X _ Liauid depth = p Y Distance from founclation___ -------Distance to nearest lot line--4-__-_______ Disposal Field: Distance from nearest well______..__ ` Number of lines------------- Cength of each line__..:4, --- -Width of trench_______a` ----------- /� Type of filter material_______I, _T-T► 1�pth of filter material________/rte__Total length_____________1__ ----_----------- Seepage Pit: Distance to nearest well___________________-Distance from foundation____________________Distance to nearest lot line=______________ " N 1-1 Number of pits----------------------Lining material-----------------------Size: Diameter----________ p Cesspool: Distance from nearest well________________Distance from foundation------------------- material------------------------------------- ❑ Size: Diameter-------------------------------------Depth----------------------------------------------------Liquid Capacity----------------------------gals. Privy: Distance from nearest well--------------------------------------- --- Distance from nearest building------------------------------------------ ❑ ----------------------------------- ' Distance to nearest lot line-- ---------- -------- - ------------------ --------------------- - - ---------------- Remodeling and/or repairing (describe):--------------------------------------------------------------------------------------------------------------------------------- ------------------------ -- - -- - - - - --------------------------------------------------------------------------------------------------------------------------------- 1 hereby certify that l have p-repared 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) - ------- ------ -------------- -- ----- ------------ - By:----� y ------------------------------------------------------------ -- - - (Title -----•------------------------------------ - (Plot plan, showing size of lot .oc tion of s stem in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATIONACCEPTED BY-------------------- �'-------------------- ---------------------------------------- DATE----------101,71 - -44v-- !---------------- REVIEWED BY--------- ------------------------- ------------ ----------- --------- ------------ ------------ ---- ----------- DATE----------------------------------------------------------- BUILDING PERMIT ISSUED-------------------------------------------------------------------------- -- ------------------------ DATE--'---- Alterations and/or recommendations:------------------------ ----------- ------------------------------_------ -- ----------------------- �� - - --------------------------- FINAL INSPECTION BY:------ -�� --------- Date----------��-----� - -� ----; - SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Street 814 North "C" Street S+ockton, California Lodi, California Manteca, California Tracy, California ES-9--2M B-51 Revised W-2100