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n APPLICATION FOR SANITATION PERMIT Permit � (Complete in Duplicate) �. Data issued :__.__l_./� 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. 54 JOB ADDRESS AND LOCATION__._ Owner's Name______ ------------------------•----------------------------• --------•----------------------- ,r-_-- r - � - - --- ------- --- ------ --- - --- -------- -------- ------- ----- one-------------------------- Address-------------•-----••- --�wf.----.- _- , Contractor's Name----- •-----•---- - ------� � one e-------- - ----- ------------- one---•--------•----- Installation will serve: Residence -----`----------• Aparfiment House ❑ Commercial ❑ Trailer. Court ❑. Motel ❑ Other ❑ Number of living units: ____.__ Number of bedrooms -�__ Number of baths Z-__ Lot size __�_- ------------------------------ C ----- -------•------------•- Water Supply: Public system-[i�Community system ❑ Private ❑ Depth to Water Table Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam [] Clay ❑ Adobe❑ Hardpan El Previous Application Made: Yes ❑ No �New Construction: Yes ❑ No �HA/VA: Yes'E] No � f TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or'cesspool permitted if public sewer is available within 200 feet.) f ptic nk: Distance from nearest well-----------------Distance from foundation____-------- -------_Material ____ ._:________.______-________- 6//� No. of compari-menu--------------------------Size_- ----- -----------.. Liquid'depth--------------------------Capacity-- -------------------- ` ispos field: Distance from nearest well_________________Distance from foundation__________-_. -.:-Distance.to nearest lot line Number of lines-------------------------- Length of each line----------------------------- Width of trench--_______•--------- I Type of filter ------------------- Width of filter material - --- ---------- ----Total length----------------------- ----------------- Seepage Pit: Distance to nearest well_ _Distance frgm foun ation_ P_--:____.Distance to nearest lot line__-�----�__ Number of pits�'_�_______-___-__Linin material /� I 9 ,,c�- Size: Diameter_s�------------.Depth_.._ , -_-!-_---- ------ Cesspool: ❑p Distance from nearest wel!____-_______.'_Distance from foundation_______________r-__.Lining material-_-__-.___-_-___-__.-___._______- v� Size: Diameter----------------------- -------------Depth--------------------------------------------------- ILi uid Ca aci ---------.gals. V Privy: Distance from nearest well ------------- ___________ Distance from nearest buildin Distance to"nearest::lot line------'-`--" �---�---- - 9---- ------- -- ----------------- + , Remodeling and/or repairing (describe):-__-_________- 40_0 11W2 --------------------------------------I---------------fi -----------------•--------------- ----------- ------------------------------------I---------------------q---- _•-------------- -----------•-----•-----------•----------•----•-----•------=------------•---------------------------------------`----.._ ordinances, State laws an `----------------•---------------------------------------------------------------------------------------------------------------------- ---------- -------- ------------------ -------- ---------- - -------- I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County rules and 3f gulations of the San Joaquin Local Health District.' (Signed) a ------- - -- - ------ -- - ----------------------------------- � Confractor) $Y� ------------` _ --------- - ------ -y---------------------- -----(Title) (Plot plan, showing size of lot, loc n of system in relation to wells, buildings, etc., can be placed on reverse e). -------------- FOR EPARTMENT USE ONLY APPLICATION ACCEPTED BY------------------------------ --- DATE REVIEWED BY-----------------•--------------- ------------------------------ -----=---..-------- ------ - --- -------------------- ------ -- ------- ----• --------- --------------- BUILDING PERMIT ISSUED DATE ------- _.------------------------------------ DATE Alterations and/or recommendafions:______----------------- -------------------------------------------------m--- --- ------- - ------- j7_____- - -• ••---•----------- t - - ---------••------------------------------------------------------------- --•--------•-- - FfNAL INSPECTION" BY------------=- I Q� ------------- �" J Date -- ---- -- SAN JOAQLI N LOCAL HEALTH DISTRICT 130"South American Street 300 West Oak Street 132 Sycamore Street 814 North "C" Street Stockton, California I Lodi, California Manteca, California _ Tracy, California ES-9-2M Reviseci 1-57 F.P.CO.