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L4 ©a k APPLICATION FOR SANITATION PERMIT Permit No. .__l _.7__ � (Complete in Duplicate) /0 Date Issued Application is hereby made to the San Joaquin Local Health District fora permit to construct and install the work herein described. This application is made in compliance with Count Ordinance No. 549. r JOB ADDRESS AND L CATIO _. _ � _____ S _ -•- } OwnersName- ------------------------------------------------------------------------ Address +��y� ------ -------------------------------------------------------- Contractor's Name-----------------------------lam--.-•-- --------------- --- - -------------------------•---••- •-----------------•---- Phone----------------------------------- Installation will serve: Residence XApartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: ._._.__ Number of bedrooms ----/. Number of baths _I___._• Lot size ----- _Z-A--./Q..©______________________ Water Supply: Public system ❑ Community system �r Private ❑ Depth to Water Table 110. ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay Adobe❑ Hardpan ❑ Previous Application Made: Yes F-1NoJ New Construction: Yes No ❑ FHA/VA: Yes E] No P TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or'cesspool permitted if public sewer is available within 200 feet.) Septi Tank: Distance from nearest well_-f'p074&stanc from found C72 --•-� No. of compartments______ ___________Size___, _____._ _X_�__Liquid depth____4arii _ �l Disposal Field: Distance from nearest wel164-- "6istance from foundation___-711Q. Distance to nearest lot linn.___��__.. Number of lines_______""___ ____ -- Length of each line.'"'-_._____Width of trench------ Type of filter mate ria --Depth of filter material______ __________Total length...$_O___ 9_9 --------- O Seepage Pit: Distance to nearest well---------------------- from foundation....................Distance to nearest -__________- ❑ Number of pits----------------------Lining material----------------------.Size: Diameter------------------------Depth-----------------__________-____- Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material-------------------------------.___-_. ❑ Size: Diameter-------------------------------------Depth---------.-------..--------------------------------Liquid Capacity-. ------------------------gals. Privy: Distance from nearest well------------------------------------------------- from nearest building__.__.------------_..__.___-_____________- ❑ Distance to nearest lot line----------------------------------------------- ............................------------•---------_ ---------------------------------- Remodeling and/or repairing (describe):-------------------------------------------------------------------------------------------------------...................------------------•--•••---•- . ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ r - -------------- •-•--•------------------------------------------------------------------------------------------------------------------------ ------ -------------------- --------------------------------------------- ---------------------------------------------------------------------------------------------------------------------------------------------------------- I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, SFa laws, and rules and regulations o e San Joaquin Lo al Health District. _ (Signed)--- -------- --------- ------ -- ----------------- ___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 ------------------------------------ ---------- ----------------- DATE - -- -------------------------- ------------- REVIEWEDBY----------------------------------------------------------------- . -- --- - DATE.---- ------------------------------------------------------- - PEtISS •-----_------------------------------ ....................................... DATE------------------------••----------------------------------- Alterations and�or re mmendations: - ---- -------------------------------------------------------------------------------------------------------------------------------------------------------------•-------------------------------- -----------� `---- ---------------------------------------- -------------------------------------------------------------•-----------••-••......----------•- -------------------------------------------- ----- - ---------- ---------------- ---------------•-----------------------------.............................................. ................................................----..----------------------------- •---•----- - ---- ----- -------------------------------------------------•--------------------------------------------- ---------_ --•--------------- FIN INSPECTION BY----------- --------- ---- Date---------- ---------------------------------------_------------------------ ------------------------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Street $14 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California ES-9-2M : Revised 1.57 F.P.CO.