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} 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. i This application is made in compliance with County Ordinance No. 54Y. 1 JOB ADDRESS AND LOCATION. --------- - ------------------• ----------------- Owner's Name ------- ---------------- ----------------- ------ Phone_ _ "_� .oa Address-- /��/ ------- - -------••---------------------------------------------------------------•-------------------------------------------•------- Contractor's Name-------------•--- - -- --------- -------- -----?------------_----------------------- ------ Phone 4_`-f-d'�47- s Installation will serve: Residence Apartment,House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: .--- Number of bedrooms .- Number of baths -!-__-- Lot size ____________________ � � 4 Water Supply: Public system 2--community system ❑ Private ❑ Depth to Water Table '�a ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe D--Hardpan ❑ " Previous Application Made- Yes ❑ No O�New Construction: Yes ❑ No ©� l TYPE OF INSTALLATION AND SPECIFICATIONS: _ (No septic tank or cesspool permitted if public sewer is available within 200 feet.) j c.Tank: Distance from nearest wel------------------Distance from foundation--------------------Material ___________.__._____.___---.-.--________-_-_. No. of compartments--------------------------Size------------------------•------Liquid depth------------- -----------Capacity----------------------- isposal.Field: Distance from nearest well.................Distance•from foundation--------------------Distance to nearest lot line________________- ` Number of lines-----------------------------------Length of each line----------------...___-------Width of trench.---------------------------_--_--. Type of filter material---------------- of filter material-----------------------Total length_____.__._._________--_-_-_--___-_-____-- seepage Pit: Distance to nearest well�_J�ldDistan rom fo tion----J.Qj.___.Distance to nearest lot line-_-S_-_�______ Number of pits...... / Linin mater•al__�romfoundaficn ize: Diameter._.123� _--.--.-Depth___$7*-_-_____________ �\ Pf------------ g Cesspool: Distance from nearest well________________Distanc ---._.......______..Lining material.---------------.-_.__-_._-___._.____- Size: Diameter ----------------------------- -----Depth------------------------------------------------1--Liquid Capacity------.--------------------gals. : PrivY Distance from nearest well----------------------------- --------------_--- - Distance from nearest building------------------------------------------ ❑ Distance to nearest lot line--------------------- --------------------------------------------------------�,k------------------------------------------------------------- Remodeling and/or repairing (describe):--------- -------- --------------- ---------•-•-------------------------------------------- - -----------------------------------•-------- { --------------------- ------------------ ----------------- ------------------------------------.....------------------------------------------------------------------------------ ---------------------------------------------------.} -- _.. ` ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, Stat laws, and rules and regulations of the San Joaquin Local Health District. ------- --_--------------------------- --------------------------------------------------------.Owner and/or Contractor {Signed}----•--•--•- - - � { � I By:------------------ - / -- 7^--------------------------------------------{Title} r - (Plot plan, showing size of lot, location of sysfe in relation to wells, buildings, efc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY--------------------- -- --- ------ ------- DATE - -- ------------------------------------------- REVIEWED --_- -- REVIEWEDBY-------------------------------------------- ------- - ---- --------------------- DATE : BUILDINGPERMIT ISSUED--------------------------------- --- -�,-----------------------------------------------------.- DATE----------------- Alterations and/or recommendations: --------------------------------------------------------------------------------------------------------- --- ----------•- ---- ------------------•-------------....-..------- . --- ---------- ---- f -- ----------- --------------- -------•--- -- -- -------- - - -- - •-- . --------- --- --------, -- -- --•- '. '"t ---------------------------------- --------------------------------- --------------------------------------- -- -- - - -------- FINALINSPECTION BY:............ .fes ------------ .............. Date--...-------- --`... -- -- -' ---------------------------------------------- 4 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 ES-9 745446 ATWCUo