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APPLICATION FOR SANITATION PERMIT Permit No. .. ---------------- �' .. { (Complete in Duplicate) ��T1 t / Date Issued Applica4ion 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. r Ai�__fJOB AQQRESS ANQ LOCATION-----------�7�"--�---�J----------- `"�-- ------------------------------------------------------------------- -- Owner's Name---- 1 f 2 T------�c!.Te�f'ErQ �.4-p �j Tll � - Phon `''2 -- -- Address--------------------------------------------'Q-19-p-n-e---------------------------------------------------------- Contractor's Name__________________________ _____ '- F '+ _- _S Phone.,-3-4 7 Z d Installation will serve: Residence ❑ Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other Number of living units: __1___ Number of bedrooms __ _ Number of baths -_t____ Lot size ------- v.k _� ! -------------------- Water Supply: Public system 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, Hardpan ❑ Previous Application Made: Yes No ❑ New Construction: Yes ❑ No TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) yyt Septic Tank: Distance from nearest well _____Distance from foundation__._16_r___-Material_____1___ -...__- ---------------- No. -------------- No, of compartments_______-__-�'"____-_-_.Size____ _ _✓_.___Li uid de th____.!_-v Ca �aci C Q r Disjpossa Field: Distance from nearest well.._'.""'_...._Distance from foundation---fd_(___._.Distance to nearest lot line_____ � \ Number of lines- ---- ------- ----------Length of each line---------ti.t� _4__._ i_-.-.Width of trench--------- !, ____-- Type of filter material___ _ ._PSe-_.Depth of filter material----__-.1c? _..... otal length----------------«_U:'________-- Seepage Pit: Distance to nearest well----------------------Distance from foundation--------------------Distance to nearest lot line_______._________ ❑ Number of pits----------------------Lining material-----------------------Size: Diameter-----------------------Dept h_-------------------------------- Cesspool: Distance from nearest well-----------------Distance from foundation---------------.....Lining material----------------------------,_-___-_- �l ❑ Size: Diameter-------------------------- -- -------Depth---------------------------------------------------.Liquid Capacity----------------------------gals. Privy: Distance from nearest well------------___-----__-----.-------------------Distance from nearest building__-_________._________________-_.--___._. ❑ Distance to nearest lot line---------------- ------------------------------------------------------------------------------------------------------------------------- Remodelingand/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)-------�---�---�---------- -----(Owner and/or Contractor) BY=-�S�-�--- �-- - - --•---- ------------------------------------(Title)---------- ------------------------- (Plot --------------------- (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--------------- - -- C--- .�--- ' REVIEWEDBY--------------------------------------------- ----- ----- - -- - ------ ---------------------------------------------- DATE------------------ ---------- -•-- ------------- BUILDING PERMIT ISSUED----------------- --------------- --------- --------------------------------------------------------- DATE---------------- - Alterations and/or recommendations:------------- - -----�r ------------------- -- --------------------------------------- --- -------- --------------•---------------------------------------s l =---- ---4 ------ -Kqc- -------��f` ------)_e---------1/14---------m5�......!?4U:-- ---- -- ---•---------------------------------------------------- ------------------------------------------------------------------ -- --------------------------- ------•------------------------------------------- -----•----------------------------------------------------------------------- L.:.. /� � '�� -----��"'----; > 'r FINAL INSPECTION BY: r1 Date---- -------------------------------------------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT r 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