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a �A� APPLICATION FOR SANITATION PERMIT Permit No.�.7— ........... (Complete in Duplicate) � "" Date Iss e 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 ismade in compliance -til County Ordinance No. 549. f � : " JOB ADDRESS AN LOCATION------------- - ----- 1 ------------------------------------ ------------------------------------------------------ Owner's Name---- A------------ — tt � ---- ----------- - ------ -- --- - ----------------•------------ PhoInel __5 ---_-l-ql/- - /_-- Address - 1 Contractor's Name..--------- --- ------•------- --- ------------------ on Installation will serve: Residence [Apartment House 0 Commercial [] Trailer Court ❑ Motel ❑ Other tthher ❑ /`� Number of living units: . -I__Number of bedrooms --- Number of-baths ---L_ Lot size ._�t/_l _Q-�_/�__md"- _•___.__ `_-_ � Water Supply; Public;system�'[Cm❑ F1ommunity systePrivate Depth to Wafer Table :_ 4ft- Character of soil to a depth of 3 feet: Sand [❑ Gravel ❑- Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe 0,'<,rdpan ❑ Previous Application Made: Yes•❑4 No [a]'�New Construct' n Ye ❑ No TYPE OF INSTALLATION AND'SPECIFICATIONS: (No septic tank or cesspool per if public sewer is available within 200 feet.) Septic T k: Distance from nearest well------------- --Distance from foundation............ __•__.Material___.----!------_-_-------------_-___-- __.___. ❑ 14No. of compartments-------•------------------Size--------------------------------Liquid depth--------------------------Capacity------------•---------- Disposa field: f Distance from nearest well-----------------Distance from foundation---------------._..Distance to nearest lot line-----------_..-_. ❑ • ' °.Number of lines`---n----------------------------Length of each line------------------------------Width of trench-------------------------_-----_--- # ..Type of filter•material---------------------------Depth of filter material---------------_-----Total length_-=----------_-_--_-__________.__-____.r Seepag +#: „ Distance to-nearest well-_-�_------Dis#anc fr oun ati" n__-a_4----..Distance to nearest lot line---_- �--_ Cumber of'pits--- Lining material__ Size: Diameter__ -..._...---.Depth__1-_�---__-___ + F Cesspool: Drstance from nearest well"-_-F-- ---_ Distance from foundation..:.................Lining material__.___--..-.---.----._------_-___-__:. ❑ Size: Diameter-- ------------------------- ----- Depth--------------------------------------------------Liquid Capacity----------- ------------- gals. 1 Privy:l Distance from nearest well---.____-_-------------------------- -- Distance from nearest building---_-.-.-____________-_--____-----.----.- ❑ =-------------------------------=--------•'--------------------------------------- near.est,lot'line------------=------r----- - ---- -------------- Remodeling and/or repairing (describe)_----------------------------- ---------------------------•-----------••----- -•--•-------------------=------------•-------------•--•-----------•-------••-•-----------------;-------------•-- --- --•----------•---------------------------------------- i I , - - - - --- ---------------------------------------------------------- --------------------------.----------------------------------------------- Iihereby certify that I have prepared this application and'that the work will be done .in accordance with San Joaquin County ordinances, State I and'rbles and regulations of the San Joaquin Local Health District. (Signed) -- ---- ---------- ------ -------------- --------------•----- ---- • - -------- and/or Contractor ZAa -_------------- By ---------- ----------- -•------ ---------------------- - -----------------------..._----------•-----------------------------------(Title) (Plot plan,.showirig size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). a FOR DEPARTMENT USE ONLY APPLICATION ,ACCEPTED BY _ DATE��- - _ REVIEWED BY - r DATE--;�,.�------------------------------ ------------ ---------- - - .. - BUILDING PERMIT ISSUED-------------- - •----------------------- ------=-------------=------------------------=--------- DATE-------- . -------------------------------------------------- Alterations and/or recommendations:._. ---="------.-............ ............. .------•--------------------...----------------•-•------_------------ E ! I -------•-- ---------------------------------- = --------- -- -•-- -----•----------------------•-------•--------------- ----------•-----------------------•-------------------------------------------=--------------------------------------------------------------------------------------------------,----- --------------- r FINAL- INSPECTION BY:.::-- --------------- Dat e------------ .----- ----- --------------------- "" - SAN JOAQUIN LOCAL HEALTH DISTRICT A 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--••2M - Revised W-2100