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C��t)Q•� (,l� ! I APPLICATION FOR SANITATION PERMIT Permit No. (Complete in Duplicate) 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 No. 549. JOB ADDRESS AND LOCATION- ---------- ---------5- • •--••----•-•. ••----------••------••••-•--- ----------------- -------- Owner's Name------- - ------ -------- ------ -------------- --- --- ---- --- Phone---------•-- --- - - Address -----_/_ A-•r_ ---- -- ------- A Contractor's Name--------- -- --- --•---- -------•--------•-------------- p�ione Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: _ ____ Number of bedrooms ----L Number of baths ----/--- Lot size .......................... Water Supply: Public system ❑ Community system !I0 Private [-] Depth to Water Table ld_ ft. Character of soil to a depth of 3 feet: Sand 4 GravSandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe❑ Hardpan ❑ Previous Application Made: Yes ❑ No [( New Construction: Yes,9 No ❑ FHA/VA: Yes ❑ No;y TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or'cesspool permitted if public sewer is available within 200 feet.) Septic Ta Distance from nearest well_________________Distance from foundation--------------------Material:._____________________-___-_----___.______-____. No. of compartments---------------------- -- Size -------------------------Liquid depth--------------------------Capacity-------- ----- 'OLO posal Field: Distance from nearest wellstance from foundation.....la........Distance to nearest lot Ii ej�.. ---- Number of lines___.______I__�_�__+•_______aM4 _ Length of each line___-__.-1f-0____._ .,,.Width of trench..__._ --------------- 2 ______________ Type of filter material__,) !-l � Depth of filter material____.___ _____Total length____��___________________________ eepaget: Distance to nearest well----------------------Distance from foundation....................Distance to nearest lot line----------------- F-1 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 ___._.-----------------------------------------Distance from nearest building_________-.___________-_________-________. ❑ Distance to nearest lot line---------------------------------------------------------------••----------------------------------------•-------------------------------- Remodelin and/or repairin escri ): K .�t-J - ---------- - -----r-- ---------------- -- +r4 -----Ae , --------------- ------...................... ------------------•------------------ --------------------------=---------------------------------------------------- -•------ 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. (Si ned 9 )-x--- 1#11t -------1`-�=P��►-`1.ki.�e!--------------------------------------------------------------------------------------------------------------(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-------------------------------------------------------------------------------------------------- DATE..-------------- ------------------ REVIEWEDBY-------------------------------------- -------------------- --- -- ---------------- ------ DATE------.......�---------4--- ,( •� 1 BUILDING PERMIT ISSUED----------------------------------------------- DATE-------------- /------------------------------- Alterations and/or recommendations------------------------------------ -- -- - . --•-----------------•------------------------------------------------------- ----------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------ -----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------•-•-•-------------------- ------------------------------------------------------------------------------------------------------------•------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------- ---------- - --------------------------------------------•---------------------------------------------- -------------------------- FINAL INSPECTION 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 Revised 1-57 FY.CO.