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APPLICATION FOR SANITATION PERMIT Permit No_ _______ _ ____ ....... (Complete in Duplicate) Date issued ______________________ Applica4,ion 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. JOBADDRESS AND LOCATION-�'A ------------`---------- ----=----------------�--�--------------- --------- -----------------------------t-----------•---------------- �. Owners Name-- t �-, Phone ----es.....• �----- - -- ---------------------------------------------------- Address Contractor's Name---------_ e ------ Pho __.._:S= �ls --------- Contractor's �..A---��--•--- ----- - Installation will serve: Residence'❑ Apartment House ❑ Commercial 2---Trailer Court ❑ Motel ❑ Other ❑ Number of living units: ........ Number of bedrooms -------- Number of baths __DZ_ Lot size ___ D4_` / a .------------ ----------- Water Supply: Public system EL] Co munity system ❑ Private ❑ Depth-to Water Table 'ys ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe E___�ardpan ❑ Previous Application Made: Yes-L] No �New Construction: Yes ❑ 0 No [+�� TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200'feet.Ix . ..,,, . _ i- Z4ePPTank: Distance from nearest well_________________Pistance from foundation--------------------Material--------------------------.-_-_-______-.__.______- No. of compartments--__ ---------------.__Size---------- ---------°=---------Liquid depth--------------------------Capacity----------------------- isp L Field: Distance from nearest well___- _..._.Distance from fo'undation________ ________.Distance to nearest lot line_________ _______ . .. _ i Number of lines_________________________----- -Length of each line-----------------------------.Width of trench.___--_._._------------------------ N Type of filter material_________________________Depth of filter material------------- ---------Total length--------------`____________________-___. (� Seepage it: Distance to nearest well______ _Distance rom.foundation____.--r_______-Distance to nearest lot line__-�-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_'_________________"' r Remodeling and/or repairing (describe) --------------------------------------------- ......-------•-----------•---------=--------------'--------------------------------------- r --•----------------•----••----•------•-----------------------•-------------------•=--------•- ----------------------.... --------------------------------------------------------------------------------- - pp ----------------•-•-----------------------._...------------•-•----------•---------•-------------------...-•---•... -------------------------------------------------------------------------------------------------- -- 3, _ I hereby certify that 1-have'prepared this application and that the work will be done in accordance with San Joaquin County ordinances, St a laws, rules and regulafions of the San Joaquin Local Health District. -` ,Frr. . ✓> �- X-400er and or Contractor(Signed)- / I By:--------- ��-� -----------------------------------------------{Title ------- (Plot - --. (Plot pian, showirf9 size of lot, location of sy m in relation to wells, buildings, etc., can be placed on reverse side). I FOR DEPARTMENT USE ONLY APPLICATIONACCEPTED BY----------------- ------------- -------------------------------------------------------------- DAT ------------------------------- REVIEWED BY--------------------------------- ------------------------------I__ DATE------ --------- ------------ - BUILDINGPERMIT ISSUED---------------------------- ----- ---------•-------------------------------------------------------- DATE- -- -- ---•-------- ------------------- Alterations and/or recommendations------------------ ------ --------------------------------------------------------- ---------------•--•------------•--------- ------------•--•--------------------------- ------------------------------------------------------------ -•---••-- -------------- --------------------------- ----------- ... 1 -----•---------------------------•------------•----------------------------------- ----•----------------------•-----•---------------------•---------•----`---------------------•-----=----- - FINAL INSPECTION BY:_`-: ----------------------------- Date_.-_ -- -- -----J .^S r5 SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 309 West Oak Street 132 Sycamore Street 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California r i ES-9-2M Revised W-2100