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APPLICATION FOR SANITATION PERMIT Permit No. (Complete in Duplicate) " Date Issued /Q-_=.1-12- 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. JOB ADDRESS AND LOCATION___ j Owner's Name -- �` '` n � �` - - " ------------------------------------. - Phone------------------------------------ Address- Contractor's Name-------------------------------- ------------------------------------------------------------------------------------------------- Phone- ------------- ------------------ Installation will serve: Residence X, fliartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: ___ __ Number of bedrooms __ "=__ Number of baths ---I---- Lot size ------------------------ Water ________________Water Supply: Public system ❑ Community system ❑ Private Depth to Water Table � ft Character of soil to a depth of 3 feet: Sand �, Gravel ❑ Sandy Loam ❑ Clay Loam ❑ C?—y Ad"obe [j Hardpan❑ Previous Application Made: Yes ❑ No t, New Construction: Yes 1% No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public!per is available within 200 feet.) --------- Dista - \, Se t* Tank: Distance from nearest well---- Distance frc rn fro on ___I__ _ ___.Materi I_ _._ A I No. of compartments_____ .-11,r__ �t� _ Ca acit � e� Size = � /=`Y°iquid depth -- -- p y Disypsal Field: Distance from nearest well ___- .z_-'" ___Distance from foundation----- __--_.Distance to nearest lot lie____ .___. Number of lines---------''' „►_ _ Length of each line_ ...a k^- -------Width of trench ,a_{ Type of filter material____,S_ j _"__-&pth of filter material_______t�_g____.__.Total length-___ __ _----_______________--- 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: ___________ __-___________Size: Diameter--------------------------------------Depth--------------------------------------------------Liquid Capacity----------------------------gals. Privy: Distance from nearest well-----------------------------------.------------:Distance from nearest building----------- _ ______________- ❑ Distance to nearest lot line-------------------------------------------------------------------------------------------------------------------------------------------- fi Remodeling and/or repairing (describe) ` � rf _.-'�.a:_�t,. ___.._ ,-�`_-- -" `-- - .•-_1'"a�}"--�C:.C.r�S!5 =� ,.,_ .__i-r-___- -- ---�-`-` -- -- --- -- - --------r----------------------------------- 7 J ' ----- --- -^'_ '�__'_�:r 2_,�:r___:(_✓J--7�,. --`-'" r�-1 f-/-- ----------------------------------- t`' ------------------------------------------ -- ----l`--- - ---------------------J --------- t /adv a - - -- -- - - -------- -- ----------- - ------------------------------------------------------------------------------------------------------------- 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. (Signed)-- �--- - --- - --------------- ------ --------- ------------ <_--------------------------------------- - ------ ---------(Owner and/or Contractor) By-------------a-----------------------------------------------------------------------------------------------------------------------(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 ACCEPTED BY----------------______ ______: ------------------------------------------------ DATE-------------- ---------------------------------- REVIEWED - ----- --- ----- - -- REVIEWED BY---------------------------------- ----------- - ----- "------------------------------------ ----------------- --- DATE -- k--------------------- BUILDING ---- - ------BUILDING PERMIT ISSUED------------------------ ----------------- DATE------ --------------------------------------------------- Alterations and/or recommendations:----------- ----------------------------- ------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ --------------------- --------------------------------------------------- -------------------------------------------------------------------------------------------------------------------------------------------------------------. ___________ ___________ ___.__-___-.--_ _-__.__ - .---------------------t.____.._ -------------------- ----------------------------------- -- -_.-. _------.----_--_--__-_-__ -_ __-__----__-__. FINAL INSPECTION BY:------------- .. j'_ 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 8-51 Revised W-2100