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APPLICATION FOR SANITATION PERMIT Permit NO. ----- --------------- (Complete ----_---- --(Complete in Duplicate) 2 r T 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 Ordinan& No. 549. cv JOBADDRESS AND LOCA��TI)ON--- - ----- ------------ --------;--------- - -----------------------------••-------------------------- -------------------------- ------•- ---------------- Owner's Name - !4G•!_ ------------------- ------------------------------------------------------------------------ Phone - Address ....... /------------- ----------------- ---------------------•-----------------------------------•------------------------------------•---------------------------------------- Contractor's Name--- --- - ---------- -- ------••----------------------------------------------------- -----------------•------------------ Phone----------------------------------- Installation will serve: Residence//[v Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: --_I umber of bedrooms ---/--- Number of baths --�l---- Lot size ---&.0_-k�_Q.0----------------------------- Water Supply: Public system Community system ❑ Private ❑Depth to Water Table -------- ft. Character of soil to a depth of 3 feet: Sand Gravel E] Sandy Loam.E] Clay Loam E] Clay ❑ Adobe�rdpan [IPrevious Application Made: Yes ❑ No New Construction: Yes Rv No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic pk: Distance from nearest well-----------------Distance from foundation--------------------Material_____-_-----__----____-________-_-__-----_--- No. of compartments--------------- / Size Liquid dept --------------------------Capacity...._----- Dispos Fi Distance from nearest well___ T_T Distance from foundation- - _-_ -__.__ - istance to nearest lot fi��n�j- ------------ Number of lines___________ ___y�_'J.__________Length of each line---------- --_ ___{�+f-_--Width of trench __---_ _7___ ------__----- Type of filter materi 1.1 Depth of filter material__ --------Total length-___ Q -___-._.__________________ 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------------------------------------- 17 _-----._- _-----____----_-__--__-❑ Size: Diameter----------------------------- --------Depth-----------•----------------------------------------Liquid Capacity----------------------------gals.. Privy: Distance from nearest well---_---_____----------------- ----------------Distance from nearest building---------.______-____-___--_____--..____ ❑ Distance to nearest lot line--------------------------------------------------------------------•------•------------------------•---------------------------------------- Remode'nc� an or repairin escr e) -- - -- ------ _.� �} r -------------------•-•--------- ------------ ...... ___ _______ 1 ... ---. - -_-__ ____---_-____ . ____ _ _--------------------------.......___-.....__.---___-__---_----___-_--._--__- -------------------------------------------------------------- /y��(j/ ----..L Y I hereby certify that 1 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 Sae'Joaquin Local Health District. (Signed)-- 2/77 `' - ------------------------------------ -------------------(Owner and/or Contractor) By:.------------------------------------------------------------------ --------------------------------------------------------------(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---- •-------------=----------------------------------- ---------------------------------------- DATEs:�- - ------ - REVIEWEDBY------------------------------ -------------------------- ---------------------------------------------- DATE-------- ---------------------•----------------------- BUILDING PERMIT ISSUED------------- ----------------------------------------------------------- ------------------ DATE------- - - - Alterations and/or recommendations:-------------------------------------------------------------------------------------- F. ---- - �� (f ------ --------- ------------------ ------------------------------------- - - =�E; - —------------------------- �� .------------�� f --------------------- ---------- 7-,4 ---- - - -------- - T---- ------------------------------------- f +� ...- ► , € _ -------------- ---------- ---------- ------------- -------------- ----------------------- ---- - ----------- d�FINSPECTION BY: ----- ------------- 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 B-51 Revised W-2100