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APPLICATION FOR SANITATION PERMIT Permit No. ------- S........ (Complete in Duplicate) t Date Issued .g� 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 Ordi an o. 549. JOB ADDRESS A LO ATI --- - -- -__ �� ---------- --- ------------------------------------ --------------------------------------- -- Owner's Name-.-- __--! I t ----• ---- Address--- ---- -- Phone- -` - -- ------------------------------------------------------- ---------------------------------------------------------------------------------------------------- 'Contractor's --------------------------------- -----------------------------•--------------- 'Contractor's Name--- ---------------- -------- ----------- ------- Phone--------------------- -------------------------------------------- -------------------------- Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ 91te /❑ Other� rNumber of living units: ---/--_ Number of bedrooms _I__ Number of baths ---1_-_ Lot siz __ X �l Water Supply: Public system ❑ Community system ❑ Private Depth to Water Table --------- ft. Character of soil to a depth of 3 feet: S;�ONew Gravel ❑ Sandy Loam E] Clay Loam [3 Clay E3 Adobe Hardpan E]Previous Application Made: Yes E] No Construction: Yesr❑ No TYPE OF INSTALLATION AND SPECIFICATIONS: W (No septic tank or cesspool permitted if public�;ewer is available within 200 feet.) I SepticTank: Distance from nearest well__ 0 _Distanch X fo n�tion----L-19---------Materi Ir-------------____--___---�-} No. of compartrrients r Size Liquid deph ----- ---------- ------CepacitY C�__� t Dispose Field: Distance from nearest well__059-----Distance from foundation-___'-fZ---_---Distance to nearest lot line------ _----_ { Number of lines----------- ---------- ----- - Length of each line------J-0-0_------ Width of french-------c-i-�f_ ---_--- Type of filter material- _2_j]-aa. __Depth of fi#ter material-----Le..----- ---Total length---------JQQ----------------------- 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 we11-----------------Distance from foundation--------------------Lining material---____----_____ ❑ Size. Diameter--------------------------------------Depth-------------------------- Liquid Capacity gals. ----- Privy: Distance from nearest well----------------------------- ------ f ------__----Distance from nearest building----------------------------------------- ❑ Distance to nearest lot line Remodeling and/or repairing (descri'ee):__--/ AI�� e :t_ - -_- I ---------------•------.---• -----•----•------------------------------------------------------- { --------------------------------- --------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- I hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State lawsVandrules and regulations of the San Joaquin Local Health District. Si ned � A--------- By:-----------------------------------------------'----------------------------------------- -- - -- - Title ner and/or Contractor) ---- ------- -------- -------- ------------------------ i )---------------------------------------------------------------- (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side)._.,_.- '{ i I FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY------ - - -------------------------------- --- ------------------------------- DATE--------- -- ---- REVIEWEDBY '------------------------------------------------------------------------------------ DATE BUILDINGPERMIT ISSUED------------------------------------------------------------------------------------------------------ DATE.- Alterations and/or recommendations---------------------------------- ---- ------------------------------------------- • -------------------------------------------------------------- -----•-•-----------------------•---------------------------------------------------------------- --------------- ------------------------------------_---------------------' FINAL INSPECTION BY:--.,-,,------ - ---__-----_-' i .. ,�/ Date -----------------------------------------------•--------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Street 814 North "C" Streef Stockton, California Lodi, California Manteca, California Tracy, California ES-4-2M 8-51 Revised W-2100 #