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APPLICATION FOR SANITATION PERMIT Permit No. --l'--7e�.7-_ � (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----- DO- ------ -------------k�fi_------- Owner's Name------ e 4----•---- d_i✓s _ r5-------------------------- -------------------------------------------- Phone-----------------------•----------- Address------------------•------------�-- --- --------------------------------------------------------------------------• ----------------------------•------------------••---------------------------- Contractor's Name----------- -•--- - ----------------------------------------------------------------------------------------------------- Phone----------------------------------- Installation will serve: Residence M Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: ---/--- Number of bedrooms `3-__ Number of baths __if-___ Lot size --------_---------------------------________________________ Water Supply: Public system X Community system ❑ Private ❑ Depth to Water Table -------- ft, n Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe Hardpan ❑ Previous Application Made: Yes ❑ No M New Construction: Yes tK No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tank: Distance from nearest well-----------------Distance from foundation----.---------------Material--------------------------------.-----------____.( „ ❑ No. of compartments---------- --------------Size--------------------------------Liquid depth ------------------------Capacity---------•-•---------- Q Disposal Field: Distance from nearest well----------------Distance from foundation----------------.'_Distance to nearest lot line__------__-.____. Q ❑ Number of lines-----------------------------------Length of each line--------------------------'-.Width of french------------------------------------� Type of filter material------- -------Depth of filter material---------------- Total length------------------------------------------ Seepage Pit: Distance to nearest well----------------------Distance from foundation__ _ _:-. istance to nearest lot ❑ Number of pits----------------------Lining material-----------------------Size: Diameter-----------------------Depth--------------------------------- Cesspool: Distance from nearsir well'? ion from �oundation___ ___------Lining material_ Size: Diameter--- ------... - --------- ---------------- Liquid Capacity �� r gals. Depth------- Privy: Distance from nearest well-------_--------_--------------------------------Distance from nearest building------------------------------_----._._._- ❑ Distance to nearest lot line------------------------------------------------ ( g ribef:----------------------------------------------------------------------------------•------------- -------•-------------------------------------••-------- Remodelin and/?r repairing {desc --------------------------------------------------- '- ------------------------------------------------------------------------------------- - .i ---------------I----------••-----------------------------------------------------..--------------------------------------------------- I 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)- = --1 — ! �' '"z`` 6 ------------------------------ (Owner and/or Contractor ------- ----- ---{ -- - -- -'----------------------------k-------------(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 --- --- - -------- r r -------------------- DATE------ ------ ----------------- REVIEWEDBY--------------------------------------- ------------------ ---------------------- ---------------------- DATE BUILDINGPERMIT ISSUED-------------------------------------------------------_-----------------*----------- ---------- DATE------------------------------------------------------------- Alterationsand/or recommendations:----------------------------------------------- -----------------------------•--------------------••-----•--------------•----------------•------------------- --------------------------------------•--------------••--••------------------------------------------------------------------------------------------------------------- ----------------------------------------------------------------------------•------------------ ------------•---•---•----- -------------------------------------------•---------------- Date 4.__. FINAL INSPECTION BY:.------- �� -- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street f 30o West Oak Street 132 5ytamore Street 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California ES-9-2M I0-52 Revised W-2100