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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. 25`0 — 1,2— � s 5-O JOB ADDRESS AND LOCATJQN- /I[.v. - t------ --------------------------------------------------------- U------------------------------- Name---------- -�1h • -------------- ----------- --------------------------------------------------------------------- ---------------- Phone----------------------•------------- 0 A0 Address-------�jL4 �`-`- ---------------- --------------- Contractor's Name ---- - - --------- --- Prone_.. y Installation will serve: Re idence ❑ Apartment House ❑ Commercial [ Trailer Court ❑ Motel ❑ O Number of living units. __...___ Number of bedrooms ________ Number of baths ________ Lot size _�`Y� ---- Water Supply: Public system ❑ Community system ❑ Private j< Depth to Water Table -Ym- ft. Character of soil to a depth of 3 feet: Sand 0 Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay U� Adobe ❑ Hardpan ❑ Previous Application Made: Yes ❑ No 9 New Construction: Yes K No ❑ FHA/VA: Yes ❑ No 1Y TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or'cesspool permitted if public sewer is available within 200 feet.) } 4 r �I Sep i Tank: Distance from nearest well___`Qa____Distance from ou�ion__._)_0-_____.__.Ma r�l____ _ ____________ __.._____ rM No, of compartments--------�1 _- ----------Size �_X_ -- -------Liquid depth---- --- -1 ----_Capacity -- Disposal Field: Distance from nearest well--19'6)---._Distance from foundation----I ---------- to nearest lot �n�f � _ _ Number of lines------/_______________---_ . Length of each line_-___--- _ _ --------Width of trench___ Type of filter material- Y- y_-_Depth of filter material___1_$_ -_________Total length_____-- _c ______________________ Seepage Pit: Distance to nearest well----------------------Distance from foundation--------------------Distance to nearest lot line____-________.._ ❑ Number of pits----------------------Lining material-----------------------Size: Diameter-----------------------Depth--------------------------------- Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material--------------------------------- ❑ Size: Diameter------- ------------------------------Depth--------------------- -----------------------------Liquid Capacity----------------------------gals Privy: Distance from nearest well------------------------------------------------- from nearest building_____________-_________________-_________- ❑ Distance to nearest lot line--------- ----------------------------------------------------------------------------------------------- -------------------- f Remodeling and or r p ijing (describe):----- -—--�'�----`-----��--------------- ----- ------------------------•---------------- -/�E� ' ` -------------•------------------------ ------------------------- i' �� -----------------------------------w-------------------------I----------------------------------------------------------------------------------------- -------•----------------------- I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State and rules and regulations of the San Joaquin Local Health District. " r (Signed)------ --- ---- �- - ---------------------------------------------------------------------------------------------(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 APPLICATIONACCEPTED BY------------------------------------ - - ---------------------------------------- DATE--------------------------------- l------------------- REVIEWED BY--------------------------------------------- ------------- --- - ----- ------------------------------- DATE---------- -----Z--,"- --------------------------- BUILDINGPERMIT ISSUED------------------------------------ ---------------------------- DATE------------------------------------------------------------- Alterations and/or recommendations:----------- -------------------------------------------------- ---------------•------------------------------------ -----------------------------------------------•---•-------------------------------------------------------------------------------------------------••---------------------------------------------------------------------- --------------------------------------- --------------------------------------------- ---------------------------------------------------------------------------------------I------------------------------------------------ ---------------------------------------------------------------------- --------------------------------------------------------------------------------------•----------------------------- ------------------------------- FINAL INSPECTION BY--------------- -------------------- -- Date.......A------- 2-77n--6--/' ------- 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-9-2M , Revised 1•57 F.P.CO.