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APPLICATION FOR SANITATION PERMIT Permit No. __ ....... �I (Complete in Duplicate) `7171j_75_ Date Issued .__..../ ........... 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. i JOB ADDRESS AND LQCAjaN------__4,S___?___/__� t---1` ../---/_ Owner's Name------... ' ...f----- C..Z.�---------------------------- --- Phone.................................... Address----------------------` .......................................................................................................................... Contractor's Name.............................. ---------------------------------------------------------------------------------------------------- Phone................................... Installation will serve: Residence Rr Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other p Number of living units: J Number of bedrooms •_Number of baths ---I.. Lot size ..___.. . ........................ Water Supply: Public system e"Community system ❑ Private ❑ Depth to Water Table M_. ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe 0/mardpan ❑ Previous Application Made: Yes ❑ No ❑ New Construction: Yes ❑ No 200, TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) ti T Distance from nearest well...76A.Distance from foundation...•._�A_ Material---------------___________ __________ No. of compartments--- ----------------------Size-------------------------------Liquid depth--------------------------Capacity--------------------- spcis al F' d: Distance from nearest well--X# stance from foundation Distance to nearest lot Im� ❑ Number of lines__________ ___ g f ______ ___ _Len th of each line_-_______rs�__ _ Width of trench_ ._____!�i .............. Type of filter mat erial---„�e_,/� epth of filter material-----�j ______---Total length-------------------- e a if: Distance to nearest well---"-- _ ____________ istance from foundation ..._..Distance to nearest lot line.....4----__- Number of pits___________________Lining material______________________Size:Diameter-----------------------Depth __________-_----_-__--_---- sspool- Distance from nearest well-----------------Distance from foundation -----------------Lining material------------------------------------- V, -_ ______________•----- y� ❑ Size: Diameter--------------------------------------Depth----•------------- -------- -•---= ----Liquid Capacity............................gals. \) Privy: Distance from nearest well------------------- _____________________ Distance from dearest building_______ ❑ Distance to nearest lot line------- ----------------- -------- - --------------------------------------------------------------- ------_-_---------------- Remodeling --- • - ------------- Remodeling /or rep m9 � scribe �------- --- ---------^.. •.-r •----� u'.r- ------- -- ----•- ... `' `� --•--- - ------------- ...... •-- — -------------•••-•• ................ 1 hereby rtify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, at law les and r ulations of the. San Joaquin Local Health District. (Signed)--- - - - ---------------------------------------------------------------- ----------------------------(Owner and/or Contractor) B ......................----•----------------------------- ------ ------- ---••-... --------••-•......---•-•---•----- .....(Title)------------------------------------------ ------ (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., came placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY-------- - ------------------------------------------------------ DATE........ ...•• ......... ------... ---- •---- REVIEWEDBY------------------ ---- - ----- - ----------------------------------------------------------------- ------------ DATE -.1.. ........... BUILDING PERMIT ISSUED............ ------ DATE. --• .,5 Alterations and/or recommendations:_____----------------------------------------------- -----------------•---------•------------------------------:-------------------------------------------------------------------------------•---------------------------------------------------------------------------------- -----------•----------------------------------------------------------- ------------ ---•----.-_-------------------------------------------------------------------------------............................................. ------------------------------------------------------------P----•------------ -------------_---- -------------------------------------------•---------------------•--.--•. --.................... FINAL INSPECTION BY:------ - -- / `1"---------------------------- -------- Date-------- ........................................... SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Street 814 North "C” Sheet Stockton, California Lodi, California Manteca, California Tracy, California ES-9-2M Revised W-2100