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APPLICATION FOR SANITATION PERMIT Permit No. .___¢.--3- .. (Complete in Duplicate) J c, � I A 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 Or r' arnc.- No. 549. qq JOBADDRESS AkXCAjiN IO ____ . __-_-_-.Owner's Name----- -•----•- �, ---------•---------------------- -------------------------- ------------- Phone.----------------------------------- Address----------------� --••--. ----. .. ---•------------------------------------------------------------- Contractor's Name --- ---••---- --• - ----- ----------------------- --------------------------------------------------------------- ---------- Phone----------------------------------- Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ of I Other /-� ❑ r ❑ Number of living units: ___�____ umber of bedrooms ___�___ Number of baths --- __-. Lot size ----------------------- Water Water Supply: Public system Xmmunity system ❑ Private ❑ Depth to Water Table -------- ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe Hardpan ❑ Previous Application Made: Yes ❑ - No ❑ New Construction: Yes [] No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if ublic sewer is available within 200 feet,) Septic /ank: Distance from nearest well-- istange,from foun tion ID ' ff � -------------,Mate ah------------- - --------No. of compartments------- .9------ --- size_ Y ]�( - q epth-- ------ --------Capacity Dispos I'Field: Distance from nearest w 1 _-- -�bistanc f omF fo-un�daion -_-)t-__ istance to nearest lot line 1_ _ [t Number of lines-------- ength of each line------ _Q_ f .Width of trench_______A____ ______________Type of filter materi 5. p_ _--____-- e th of filter material_-------- --------Total length___ ------------------- Seepage; Pit: Distance to nearest well____------------------Distance from foundation--------------------Distance to nearest loft line--_____.__-___.-_ ❑ Number of pits----------------------Lining material-----------------------Size: Diameter---- ------Depth--------------------------------- 4Q 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 --------------------------------- --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, and rules,and regulations of the San Joaquin Local Health District. (Signed)_.04__ _ ___,?`'=( _. -- --------------- --- ----------------------------------------------- ----------------(Owner and/or Contractor) .. ;------------------------------------------------------------------------------------------------- -------------------------------------------------------------- (Plot plan, showing size of lot, location of system in relation +o wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY DATE-- t�------------------__----------------------------- REVIEWEDBY-------------------------------"-_-_ - --------------------------------------------- -------------------------------------- BUILDING ------------------------------------BUILDING PERMIT ISSUED........... DATE Alterations and/or recommendations:-------------- -- ---------------------------------------------- ..------------------------------.----= ----------------------------------------------------•-----•--------------------------------------------•----------------------- ------•-------------------------------------------------•-----------•------------------------- --------------------------------------------------------•---------------------------------------------------- -------------------------------------------------------------- ----------------------------------------•-- ---------------- ------------------------------ - •-----•--•----------------------------------------••------------------------------ ----•------------------------•------•-------------------------------------- FINAL INSPECTION BY:-.------- ---------------------------•---- Date--- 1 --- ----- T `s 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 10-52 Revised W-2100