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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. ,l� - JOB ADDRESS AND LOCATION......./,—/. . ...----.. _dr.5...............................-------------------------------------------------- Owner's Name--------------------_- :xt.xl -------- ---------------------------------------- Phone------�------------------------- Address..................... -----------------------Address-------•----•-•-----• -•-----••--------•-----•--- - ----- ,... .... 's-------------------•---------------------------------------•----------------------------------- Contractor's Name..&/ t ------•--------------- ------------------------------------------------------------- ------------------.. Phone----------------------------------- Installation will serve: Residence IM Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ O h r ❑ �� s --� Number of living units: _/___ Number of bedrooms _�__ Number of baths -l_._. Lot size __.._�_________�_�_ __ ________________________ Water Supply: Public system Ef Community system ❑ Private ❑ Depth to Water Table -------- ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam Fj Clay.Loam F] Clay ❑ Adobe a Hardpan E]L'7. Previous Application Made: Yes ❑ No New Construction: Yes No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet..]_r Septi Tank: Distance from nearest well ---------------Dista a fro foun tion____1_(!_ ___-_.Mater' �__________ ______1` ____. ------- En No. of compartments------- -----------Size. x •Liquid c}e th_. ___----._Ca acit Dispo I Field: Distance from nearest II-----'--_-_---Distance from foundation.. .[�._�_ '4stance to nearest to Imp." ---_----. [! Number of lines_._______. .^:____-/5d_____ __Length of each line---------- _ Width of french.._._... /� --------------- Type of filter materi n f _ Depth of filter material.._._._.. __.__Total length___.......f_ /.V___________________ Seepage Pit: Distance to nearest well__,-------------------Distance from foundation....................Distance to nearest lot line----------------- El Number of pits---------------------Lining material------------ ------Size: Diameter-----------------------Depth-.------------------------------- Cesspool: Distance from nearest well_________________Distance frodation--------------------Lining material----------..-_______._____-_-_-_---- El Size: Diameter--------------------------------------Depth__________________ Liquid Capacity----------------------------gals. Privy: Distance from nearest well--------------------------------------!__--_-____Distance from nearest building------------------------------------------ Distance __-_.___.____---_-_-__-___-__._-.-._.Distance to nearest lot line---------- ------------------------+I -----------------------------------------------•---------•---------•--•------------•------ Remodeling and/or repairing (describe):--------------------------------------------••- -------------------------- --•------•-•--------•----------------------------------- -------------------------------------------------------- -------------•---•--•-----•----•-----•-•-•----------------•-----------•----•--•---------------------•------•---•-•--- --------------•----•--------•-----------•-•----•------------------•-------------•-•-•------- -__.... ._..�------------------------------------------me ..................................1._-__----_-_-_-.-_.-.-_-.--___-_--__--_-..----.__.--____ I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, Sta laws, and rules andi regulations the San Joaquin Local Health District. i (Signed)----_._ _ vf. -Ago o=----------------------------------e----------(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 APPLICATION ACCEPTEDB DATE"-- ------------ -- -- --- --- ----------------- REVIEWED BY---------------- -- --------- -------------------------•----------------------- DATE BUILDING PERMIT ISSUED-----------_ .............•-----••--••- ----------------- --•---........---•-----••--- DATE.._...---Q))------------------ Alterations and/or recommendations----------------------------------------------------------------------------------------------------•-- ---------------------------------------------------------------------------------------------------- --------------------•-----------•---..----•-------...-----...------------------------------------------•-•----•----•--- ---------------------------------------------------------•---------------------------------------------------------------------------------------•.-.-----.--------------------------------------------------------------- -------------------------------------------------------•----.----.-------------------------------------------------------------------------------.--------------------•-----------------.------------------------------------- ........................... ------------------ ------------------------------------------------•-------_------------------ .-... ----------------------------------------.------------------------------------ FINALINSPECTION BY-------------------------------- -------------------- Date---------------- / ------------------------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Street 614 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California ES-9-2M 10-52 Revised W-2100