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y APPLICATION FOR SANITATION PERMIT Permit No. V (Complete in Duplicate) Date Issued .._ /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 is made in compliance with County Ordinance No. 549. — .� -------------- JOB ADDRESS A OCATION---92_---`------- ------------ ---- �t' -------- ------- -- Owner's Name---- -- ------ ----------------- -------------------------------------------- Phone_�__!_��_.�.�----�----•--- Address-------- _6 -f.7 - --------- =----------------------------------------------------------------=............................. Contractor's Name-------- Phone Installation will serve: Residence ❑ Apartment House ❑ Commercial Trailer Court ❑ Motel ❑ Other ❑ Number of living units: -------- Number of bedrooms -------- Number of baths -------- Lot size -_-____-•._-_•--__--•-__-_•-___•____________________________ Water Supply: Public system Community system ❑ Private ❑ Depth to Water Table &V ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe 2-"Hardpan ❑ Previous Application Made: Yes ❑ No Q-----New Construction: Yes 2 ro ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) pt' ank: Distance from nearest well-----------------Distance from foundation--------------------Material___-_--_-_----_-________.___-••-___--_-- ---•.No. of compartments--------------------------Size........... -------------Liquid depth---------- ---------------Capacity---•------------------ r)lcpo ie4d: Distance from nearest well-----------------Distance from foundation---_-------------.Distance to nearest.lot line------------_--- " Number of lines---------------- --- - -----Length of each line---------------------- ----Width of trench. Type of filter material--------------------------Depth of filter material-----------------------Total length_____----_ --___-___---•-___--____ Distance to nearest well y' Distance fro fou dation_-JA to nearest lot -- Number of pits_____ _____________Lining material��_ ____�____ _Size: Diameter____ _-----__Depth------ Cesspool: --___��.�__________-._-- Cesssp o: Distance from nearest well-----------------Distance from foundation---_----------------Lining material__--___r--_-_-.-.__--________..___.-_. (A 1771Size: Diameter--------------------------------------Depth------•--•---------- ------ -----------------------Liquid Capacity-----_--------------------gals- 1 I, Privy: Distance from nearest well-__-___-__.- .__._._-___--____-.___.___Distance from nearest building__________________________________________ ^ ❑ Distance to nearest lot line--------------------- •-----------•---------------- Y�Y Remodeling and/or repairing (describe):---------------------------------------------------------------------------------------------------.................................................... -------------• --•-------•-----------•----•------------------------------•------------•-----I.............-; --------------------------------------------------------------------------------------------I---------------------•----•--------------------------•---------•---------------••---------------•---------------------- I hereby certify that I have prepared this appljcation and-that the work will be done in accordance with San Joaquin County ordinances, St laws, and es and regulations of the San Joaquin Local Health District. � ------------------- - Si ned �-- --� (O er and/or Contractor) ------------------------------------------ Title --------------------------------------- BY:---------------- ''i ------------------------------------•----( (Plot plan, showing size of lot, Iota+ion of syst in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY--------------------- ---- - ---------------------------------<----------------- DATE 9-r-1 REVIEWED BY--------------------------------------------- ----- DATE------------------------------------------------------------ ------------ BUILDING PERMIT ISSUED----------- DATE.. Alterations and/or recommendations------------------- ---------------------------------------------------------------•--•----------•••-•-•----•-•-•-----••-•-----..._......•-•••---•--•------•--- ------------------------------------------------------------------------------------------------------------------- --------------------------------------------------------------------------------------------------------- -----•-----------------------------•----------•--------------------------------------------------------------------------- ----- -------- z._..-i s7—----------------------- FINAL INSPECTION BY:---------- ----------------------------------- Date----•--------- 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 W-2100