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APPLICATION FOR SANITATION PERMIT Permit No. (Complete in Duplicate) - 2— 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 Ordinance lNo. 549. JOB ADDRESS AND LOCATION_.._____I_ _-�L_-_--__�' 7/`__•_�o-�Q�� / --------------------------------------------------------------©-----------q----- Owner's Name----------- -------- 'Q �------- r----------L�4 4J. ------------------------------------------- Phone---9 / �{ +�' Address-----------•-------•------------------------------------------------ c-- -------------------------------------------------------------------•--------------------------------------------- ----..�--------- Contractor's Name----------------------------------------- ��------------------------------------------------------------------------------ Phone----------------------------------- Installation will serve: Residence;9 Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel [❑ Other ❑ Number of living units: .4..__ Number of bedrooms ___!c_ Number of baths __/---- Lot size __________� ---k_Zda------ .p)----_ Water Supply: Public system 0 Community system ❑ Private ❑ Depth to Water Table -------- ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam [] Clay Loam ❑ Clay ❑ Adobe K Hardpan ❑ I Previous Application Made: Yes ❑ No JZ New Construction: Yes ❑ No� TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) I 4 '6' Septic Tank: Distance from nearest well__��^Q--Distance from foundation---- Material______________._ _-�__��'�' . No. of compartments---------Z------------Size__3X_4 X4 ------ depth_______ _____________Capacity______ DO______ Disposal Field: Distance from nearest well__X&rne•.._Distance from foundation-------S........Distance to nearest lot line________. (� Number of lines---------/_L2__�_T ___Length of each line_____3�t______________Width of french--------__Z w1t____-_-____---- Type of filter material__--1-_J_ ____________Depth of filter material___--____& ?`___-_Total length______-___--ip0--�-_______ 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: Diameter---:---_------------------------------Depth-----------------------------------------------------Liquid Capacity----------------------------gals. ZI I Privy: Distance from nearest well--------------------------------------------------Distance- rom nearest building--------______--_-------_________________ ❑ Distance to nearest lot line Remodeling and/or repairing (describe)--------------------------------------------------------------------------------------------------------------•-------------------------•--------------- -------------------------------------------------------------------------------------------------------------------------------------------------------------•---------------------------------------------------------------- -------------------------------------------------------------------------------------------------------------- --------------------------------------------------------------------------------------------------------------- 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)-----x_ ----- �t----------------- -- ----------------.(Owner and/or Contractor) By:------------------------------------------------------------------------------------------------------------------------------------(Tif le)---------------------------------------------------------------- (Plot y:----------------------------•-•-----------------------------------------------------------------------------------------------------(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------------ - - REVIEWEDBY ---------------------------------------------------------------------- DATE- -------- '-- -`--`-�--�--------------_--- BUILDING PERMIT ISSUED------------------------------------------------------------------------------------------------------ DATE ---------------------------- Alterations and/or recommendations------------ ------------------------------------------------------------------------------------------------------------- ------------------- - -- -------------- -------- ---- - - �--.^ ---- i' `�-'. } � - ,._ --_�-- ------------------------ -------------------------------------------------------------- --- --- -------------------------------------------- - ---------------------------------- - ------------------------- _- , ------------------------------------ -------------- FINAL INSPECTION BY:-------------------------------------------- --------------- Date SAN JOAQVIN 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 B-51 Revised W-2100