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ly APPLICATION FOR SANITATION PERMIT Permit No. ._____.. __ (Complete in Duplicate) Date Issued ___� Applica+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 OrdloAqnce No. 54 . --?s-- a. --ne r------- -0�-------------•---------- 3 JOB ADDRESS AND LOCATION------ - -------- ::� gin- Cyan. a[�s - Phone..�.� Owners Name---------------•------------- . 0M_ _�'�-----• -- ---- ------------------------------ Address------------------------------------ �/7 C.! - Phone. .--.� _7 C�' i''Ir_I_5-�-�- ----- --- ------------•-1111-- -----1111-- Contractor's Name--------------•--------------•--------------------------- --- Installation will serve: Residence D( Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑--------�----71-l--1111----_-- +. Number of living units: __ V 1--- Lot size m ❑ Private Depth to Wafter Table _J_ Number of bedrooms - Number of baths _ -- Water Supply: Public system 171 Community syste ` _'f+, �_ .,,// Gravel Sand Loarri ❑ Clay Loam❑ -Clay ❑ Adobe!� Hardpan ❑ Character of soil to a depth of 3 feet: Sand ❑ ❑ y t New Construction: Yes ❑ No ❑ Previous Application Made: Yes ❑ No� , -. su N TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Se tic T nk: Distance from nearest well--------- ------ Distance from foundation depth- Material-_--------Ca- aci ------------------------- P tY--.1111111111 11-1111-- ��Ig�1n� No. of compartments____________________ ss��•. Disposal ield: Distance from•nearest weil,�D'.._.Distance from foundation_____0-i---.Distance to nearest lot line___--�Q Length of each line--�.�--`1111-- Width of #rench�.-�--•- - i If 01 �� Number of lines_ --r�--------- g pis f ------------------- �I 7 De fih of filter material-----10-----------Total length---------------------- Type of filter material__!_1-1 4-0 ------- P Distance from foundation___________________.Distance to nearest lot lin e________________- Seepage Pit: Distance to nearest well___________-_____. - ------------- Number of pits---------------------Lining material----------------------Size: Diameter--------------- Depth Lining material Ces�ool: Distance from nearest well______-___.___--Disttahce from foundation -----------------Liquid Capacity---=w____.-_'_-_____._____gals. ❑ Size: Diameter--------------------- Dep y -1111------------------------Distance from nearest building_________---111111 11-1111-- --------- Privy: Distance from nearest well-------------- _.__.__-- -•----------------------------------------- ---------1111-- ----------------------- ❑ Distance to nearest-lot line--------------1111-- -1111-- 11111111 ------- - ` --------------- -----------------•--------- ---------------••-- Remodeling and/or repairing (describe):------------------ - :-------------_----___.___-- •---------------•------- ---------------------1111-- ------------------------------------------------------------ ____ --- - - ---- -----•------------------- -----------------------------------------------------------•--------•--------------------- ! hereby cert' that I have prepare his application and that the work will be done in accordance with San Joaquin County ordinances, Sta# la s, and ru es and re ations,of lthe San Joaquin Local alth District. ----�iC.�---P,, ,p r Contractor) ----- -- --- -- -- 1111-- ---------------------- (Signed)--------1111-- -- _ _ -- I ---1111--- 1111 ----- By: - -- (Title �1?'J. -- Qf.. By:--------------------------- ---- --------••------------------------ --- (Plot plan, showing size of lot, location of system in rellls, buildings, tc., can be placed on reverse side). FOR EPARTMENT USE ONLY 1111-- -1111-- --�-", --= _----------------1111----•---------- DAT . r APPLICATION ACCEPTED BY ------- -------- DATE----- ----------•----•------ ---------------------------- REVIEWED BY------------------------------------- --- ------------------ -------------------�--1111-- --1111-- --- . --------- DATE.-------------�---------------•----------------------------- BUILDINGPERMIT ISSUED----------------------------------------------- ------ --- - --1111-- --------1111-- ------ --------•------------------------------------ --------- -----111-------I-----------------------I---------------- -- --`----------------------------------------•---1111--- Alterations and/or recommendations:------------------------- - ---•---•---•-•-------•--•--•-•1111---...--_----• ------ ---�------------------1111-- • -------•---------- ------------------ ------------=------------1111--- -------------- --------------------------- ------------- ---------------------------------------------------- ---------------- FINAL INSPECTION BY-------------------=----- 1111-2----------=------ Date-- -- --- 1111 --1111-- ------ 1111 11 11-1111-- ---�-1111----- SAN JOAQUIN LOCAL HEALTH DISTRICT {32 5yeamore Street 814 North "C" Street 130 South American Street 300 West Oak Street Tracy, California Stockton, California Lodi, California Manteca, California FS-9-2M Revised W-2100