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APPLICATION FOR SANITATION PERMIT Permit No., ,l .,7__7__. (Complete in Duplicate) d,/! ',A � 4/ Date Issue _.___ _ _.� ._ . 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 AND LO ATION-A G%L- 10 Owner's Name phone ............................ ........ --- ---------------------- - — --- ---------- --------------------------------------- . ............................................................................................. Contractor's Name___________ _ Phone __ _.__ - T' ------- ----- --==--------4 Installation will serve: Residence Q�Apaytment House Commercial '[3'' fraiierr Court ❑ Motel ❑ Other ❑ , Number of living units: _,l_- Number of bedrooms ___ Number of baths ... ,!- Lot size -________________________ Water Supply: Public system B_<ommunity system ❑ Private ❑_, Depth to Water Table 4' ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Leam ❑ Clay Loain ❑ Clay ❑ Adobe �g--Hardpan ❑ Previous Application Made: Yes ❑ No g]- New Construction: Yes ❑ No RZ -- TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) optic Tank: Distance from nearest well_________________ Distance from foundation. ................... Material-____________-____________-________ No. of compartments--------------- - ----Sizer-------------------------- --- Liquid depth-------------------------- Capacity ....................... ispo F Id: 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 ------------------------- of filter material ----------------------- length __,___________-______-____________________ Distance to nearest well%¢ -------- Distance ro}m foundation___, 30......... Distance to nearest lot line--- ne_3d_ �k ®� Number of pits ------- /------------ Lining material_____'_!%f !'_Size: Diameter ----- 3_�__.__-...... Depth .... •? S____________________ Cesspool: Distance from nearest well ----------------- Distance from foundation ----------- .______.Lining material _____-__.____________________________. ❑ Size: Diameter -------------------------------------- Depth -------------------------------------------- -------Liquid Capacity ............................ gals. Privy: Distance from nearest well ------------------------------------------------- Distance from' nearest building ------------------------------------ _____: ❑ Distance to nearest lot line -------------------------- ----------------•---------------------------•-•--------------••---=---•----•------••--------------•---------------- Remodeling and/or repairing (describe):---------------------------------------------------------------------------------••----------•----•--------------------------•--- ---•-- ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------•----------------------------------- 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, andru� d regulations of the San Joaquin Local Health District. (Signed) ------A......... ` £ j� -- - ---- -- -- ----- er and/or Contractor) By: -----------------V' . ` ' ----- (T'itle) =` -'' -------------------- (Plot plan, showing size of lot, location of s em in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY ------------------------------------------- --------- DATE----------- -y- REVIEWEDBY---------------------------------------------------------------------------------------------•----------------------------- DATE ............................................................ BUILDING PERMIT ISSUED ................................................................ ...................................... DATE ------------------------------------------------------------- Alterations and/or recommendations: ---------------------------------------------------------• •---- --------------------------------------------------------------- -------------------------------------------------...... ------ ................................. --------------------------------------------------.._..------------------------------------------------------------------------•---------------�--L--------------------------•- FINAL INSPECTION BY: -1_1 --------------------------------- 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 Revised W-2100