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APPLICATION FOR SANITATION PERMIT Permit No. -_/-_�__a__q_9 (Complete in Duplicate) / Date Issued ____�_r___ 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 compliant w'th County Ordinance No. 549, 2.50—zSU p3 JOB ADDRESS A D LOC I , N __ � -- �f '�4` - ----------------------- Owner's Name ( --- - ---- -- l � ,� r Phone ------------------ Address -----------I----------- ----- --------------------- --- Contractor's Name___ __a___ cam___ Phone--------- ---- --- -- - ------------------------------------------------------------- -------- --- Installation will serve: Residence ❑ Apartm nt House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other Number of living units: Number of bedrooms ________ Number of baths -------- Lot size~ Z4____ _ _-----_-----__ __. ---- Water Supply: Public system ❑ Community system ❑ Private X Depth to Water Table _/.'—ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe Hardpan ❑ Previous Application Made: Yes ❑ No)4 New Construction: YesOd No ❑ FHA/VA: Yes ❑ No TYPE OF INSTALLATION AND SPECIFICATIONS: l V a. (No septic tank or'cesspool permitted if puber is available within 200 feet.) Septic Tank: Distance from nearest well--6 ____ ____Distance from foundation--------------------Material______._______.________________________.________. No_ of compartments-------------- —-- ----Size--------------------------------Liquid depth----------------- --------Capacity-------- isposal JFR : Distance from nearest well_ _ _ _ .-Distance from foundation____ __ Distance to nearestline___! l . Number of lines--------- ______ Length of each line_____!I>Q_ `r --------Width of trench -------------- 4,j, Type of filter materiaL_ �___Depth of filter material__n�l1__._________Total length-_-____l4_d_____________________page�i1: Distance to nearest well----------------------Distance from foundation____-_______-...___:Distance to nearest lot line----._-.___._- ❑ Number of pits----------------------Lining material-----------------------Size: Diameter-----------------------Dept h-_-------.-----------------,-. ), Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material------------------------------- Size: Diameter-------------------------- -----------De th---------------------------------- -----------------Liquid Capacity , Privy: Distance from nearest well-------------------____--------------------------Distance from nearest building_______________________________.____- ❑ Distance to nearest lot line------------------------ ---------- - ----------------------- ---------------------------------------------------------------- r Remodeling and/or repairing (describe):__._ ( -- £ - -----------•-------------------------------•------------- _._ .� -- ---------------------------------------------- -----•-•-------•-•------•----------------------- 4 -------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- -- I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin C666ty ' ordinances, State I , and i es and regul ions of the San Joaquin Local Health District. (Signed)-- - --------------------------------------------------------------------------------------------------(Owner and/or Contractori } 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------- --------------------- - - DATE------------------------- --------------. ---------------- REVIEWED BY---------------------------------------------------------- ----- - ------------------------------------ DATE_ •--� J tt -.:.:.. _ BUILDING PERMIT ISSUED --------------------- --------------- - DATE------- --------------------------r ---f------------- Alterationsand/or recommendations------------------- -- --------------------------------------------------------------•--------------------------------------------------------------- -----------------------------------------------------------------•--------------------------------------------------------------------------------------------------------- ------------------------------------------------- ---------------------------•-•------ ---------------------------------------------- ----------- - --r-- --------------•---- -----------------------------•---------------------------------------------- ------ `�- FINAL INSPECTION BY----------------------- - Date-- r SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Streof 300 West Oak Street 132 Sycamore Street 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California 1 ES-9-2M Revised 1-57'F,P.CO.