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APPLICATION FOR SANITATION PERMIT Permit No. (Complete in Duplicate) Date A 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 Or 'Hance No. 549. JOB ADDRESS AND OCATION----_Z d------- - --------- ----- ------ --------- ---------W----------------------•-•- %yam -----,Phone.Q{ / Owner's Name----- AddressQ u-r ' e ------ ---------=-------------------------- ;------------------------ ------ -- ---- -- . Contractor's Name Phone _ Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel y❑ Other ❑ Number of living units: __/__ Number of bedrooms .a2._ Number of aths _-)___ Lot`size _-_T�r__✓L_��r�_ e Water Supply'- Public 'system El Community system [IPrivate Depth to"Water Table.A ft. Character of soil to,a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam,❑ Clay Loam ❑ Clay ❑ Adobe Hardpan Previous Application Made: Yes ❑ No T-'�Lw Construction: Yes ❑ No TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) ------ -------Liquid depth --------------- --- p � No. of compartments------------------- -- Size---------------- -- - -- -------------------•.....................-- Se T nk: Distance from nearest well_________________Distance from foundation_______________ _ Material---- Capacity __ - P tY------- Disposal Field: Distance from nearest well____.___________-Distance from foundation___________________Distance to nearest lot line----------------- El ______`-_________ ❑ ' Number of lines-----------------------------------Length of each line------------------_----------.Width of french----------------------------------- k- Type of filter material-------------------------Depth of filter material----------------------Total length--------------------------------------_-•-- . ...... �y / --: Q' ► r I Seepage Pit: Distance to nearest w II_- 6- __---Distance from fou ation______!1__�..___.Dis an�e to nearest lot line___w--_____(`�'�.\} Number of pits---- _-_____--Lining mate rial_C_,�_e..__-. _.Size: Diameter------Xif___..____Depth____..'1�____________-- ' Cesspool: Distance from nearest weft____-_ -_ ______Distance from foundation _______.___ __.Lining material_____.._____ _____._____.___. ❑, Size: Diameter__ — Depth___.__--: =Liquid .Capacity=�'` __ gals :µ' Privy: Distance from nearest well ___ _______________ ___ .__.____.____Distance from nearest building.--_ --_- __-__-_-----_ _ .-_____. Fila Distante'fo nearest lot line________________________ -- .v.". IRemodeling and/or repairing (describe):------------------------------------------------------------------------------------------------ ---------------•---•------------------------------------ -----------------•--------------------- ----- -----------••------------------------------------•-------------------•------•--•----------------------------------- ---------------------------------------------------- � t ---------- --------------------------•--•---------------------------------------=-----------------------------------------.....---------------------------------------- ---.---•-- ----------•---•--- -------- -------------------•-----------------------------------------------`-------------------------••-----------•------------------------------------------------------------------------------------------------- --------------- I hereby certify that ]have prepared this application and that the work will be done in accordance with San Joaquin County ' ordinances, State laws, an les and regulations of the San Joaquin Local Health District. (Signed)------=------------ and or Contractor) --T------------------------------------------- 'By:--•-------------- ---- "---------------=-----------------------------------------------(Title)--- ------------------- (Piot pian-; showing..size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse sidel. FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY--------------------------------------- =--- DATE----_--____--�{ DATE---- ----- �� .. -------------------------------------=. iREVIEWED BY-----------=------------------ --- 1-------------------- --------------- BUILDINGPERMIT ISSUED---------------------------------- ------------------------------------------------------------------ DATE-.-------.- ------------------------ ----------------------- Alterafions and/or recommendations-------- ---------------------------------------------------------------------------------------------•-----•----------•-- ----`------------ ------------------••--------------------------------•-----------•--•-------•-------------------------------•----------..---------------------•------------ --------------------------------------------------- ------ F r ------------------------------------------- •-- -------------------------------•----•-------------------------------•-----------------------------------------•---------•-------------- --•------------------------------- k - ____________________________________________________________________'______.___..______.____________..___.---_-.--____--_---------- _________________________ ______ FINAL'INSPECTION"BY:--=--------------------------A-5---— ------------- 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 , ..„- f