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APPLICATION FOR SANITATION PERMIT Permit No. + (Complete in Duplicate) �• Date Issued --- --------------- 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. 549. 3 -- - ' � w JOB ADDRESS AND LOCATION-------.---��_-- �. ----�:-------��---�----____--s-- F Owner slVame-------------------------------------�-- ----_--- ---�_�(KJ{7r_!:_�'_�Com: -! !_6 1rCkcc l-ji ------------------ --- -- ,- - -- Address------------ Address------------------------- --VC I V C 'Ai:. ) fiver..._ t Contractor's Name ------°>h'---------------------------------------- - Phone. Installation will serve: Residence ❑�Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: _-!--- Number of bedrooms --_ Number of baths _!__ ? Lot size ------ ___Z____ %rs'-------------------------- Wafer ______________________ _Wafter Supply: Public system ❑ Commun'ify system ❑ Private Depth to Water Table W___ ft, i Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe [9--lardpan ❑ Previous Application Made: Yes ❑ No ❑ New Construction: Yes ENo ❑ FHA/VA: Yes ❑ No Ee-"_ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or'cesspool permitted if public sewer is available within 200 feet.l Septic Tank: Distance from'nearest well_4R�:'4.___Distance from -- foundation_ --a.__ ______-materia!____- y4` t ---------------- No'. _______________No. of compartments - - - Size- -K--�� ------ . 010 =- --- - qp -•-- i ------------ - py--- � �? Disposal Field: Distance from nearest well _'_/`�___-Distance from foundation__4�-------------Distance to nearest lot line_S __________ Number of lines___ a g r�-Width of trench----;�--f-------- -- --------- _-_`�-________________________Lenth of each line____ Type of filter material-___!' _______Depth of filter material-------A-_________Total length_�'�____r�1'_-_` —0, Seepage Pit: Distance to nearest well_____ .-------Distance . mfoundation----Lb---------Distance to nearest lot line_--- ____._ \f� Number of pits_____.________Lining materia l_ __-Size: Diameter_._ ------------Dept h____2 Cesspool: Distance from nearest well_________________Distance from foundation--------------------Lining material------------------ ---_____----___-__ �\ El Size: Diameter--------------------------------------Depth------.r---------------------------------------------Liquid Capacity----------------------------gals. `11 Privy: Distance from nearest well-----------------------------------------------__Distance from nearest building____________--__-______________________._. ' ❑ Distance to nearest lot line---- --------------------------------------- ----------------------------------------------------------------------------------------------- Remodeling and/or . epairi g (describe): ` ------- --- -------------- • --- = = -- ---------------------=------------------------------------------------------------- ----------------------------------------------------- - ---- -------- ---------------------------------------------------------------------------------- ----------------------------------- I hereby certify that I have prepared 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_,`---- --/t,'i,---n�i;-j----G'------� ��ih.��t �� -------'----------------------------------------------------------------- ------------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------ - -M ------------------------------------------•---------------------------- DATE--- - --------------•---------------- REVIEWED BY---------------------------------------------------------------------------------------------------------------------------- DATE----------------------------------------------- ------------- BUILDINGPERMIT ISSUED-----•---------------------------------------------------------•--------------------------------------- DATE------------------------------------------------------------ Aiterations and/or recommendations:-------------------------- ------------------------------------------------------------------------- -------_-------- ---------•----------------------------- - ---- - ---------------------------------------------------------------------------------=------------------------------------- - ---- -- - --- - ----- -- - ----- -- -- --------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- FINAL INSPECTION BY:---------------------!(__"--•--------------------------------- Date---------_.1 ------------------------------------------------ SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 Wes# Oak Street 132 Sycamore Street 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California ES-9-2M : Revisea ;-57 F.P.CO.