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j�� APPLICATION FOR SANITATION PERMIT Permit No. . _ Z__ ate_ (Complete in Duplicate) l 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 Ordnance No S49, / / ` JOB ADDRESS AND LOCATION--------------- --------------------------- Owner's Name-------- ------ ----- -- ----- Phone--_`"- -�x---- --- -- Address---------- ••-- --------------------- �Contractor's Name--- - --- &_ ---- ------------------------------------------------------- PhoneeZg{ & 1 Installation will serve: Residence P Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: -#---- Number of bedrooms,...- Number of baths __/__ Lot size __. *'"_'__X.oZ_• d_-___-______-- Water Supply: Public system ❑ Community system ❑ Private UgoDepfh to Water Table/07- ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe[Hardpan ❑. Previous Application Made: Yes ❑ No L New Construction: Yes ❑ No SHA/VA: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or'cesspool permitted if public sewer is available within 200 feet.) 4SfTf icT4nk: Distance from nearest well-----------------Distance from foundation-_-----_----.----_-.Material_------______--._._-- .-_--__---__.------_---.No. of compartments------------- ------------Size------------------------•--•----Liquid depth--------------------------Capacity----------------------- posal : Distance from nearest well_+S Distance from foundation____/D____------Distance to nearest lot line_ d____.. �. Number of lines_____________ _ 1�.�- ______..._____ _Length of each line_____,/�D�'d______________Width of trench- ___�_��_- Type of filter material__,5�__ Depth of filter material------ ___ -----Total length-__-/1tD_________________-_--.__ 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 ______------------------------------------------Distance from nearest bu'riding___--_-_--._----___---_---_-__--_----_---. ❑ Distance to nearest lot line.-.--------------------- -------------------- -------------------------------------- ----------------------------------------------------- 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, State laws, and rules and regulations of the San Joaquin Local Health District. / __-_Owner and/or Contractor (Signed)-------------- 1` r. / ) -- --- - -- - --- ----------- - �Y� Z .�ree.-P _..L�C.�-_ 4•- tT - ---------------------------------------------(Title) -------- ---------------------------- ---- (Plot plan, showing size of lot, location of syst in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY�-- ---- - -- ----- -- ---- ---------- -- DATE-�---------------------------------------------------- REVIEWEDBY �� ------ ----- ----- ----------------------- ----- DATE--- ------------------------------ BUILD[NG PERMIT ISSUED - DATE _=rr---------------------------------------------- Alterations and/or recommendations-------- -----------------------------------------------•--•---------------------------- ------------------ --------------------•---------------------------- -------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------._----•---------------- ---------------------------------•-----------------------•------------------------------------------------------------------••----------------------------------------------•----------------------•-•-•---•-•-----------•--- ----------------------------------•------------------------------------------------------------------------------------------------ -- ------------------------------------------------------------------------------- FINAL INSPECTION BY- ------------ ------------------------- Date------ ----------------- ------------------------------------------------ SAN ---------- - 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 3.57 F.P.CO.