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APPLICATION FOR SANITATION PERMIT Permit No. a„_k _ __--' (Complete in Duplicate) Date Issued Application is hereby made to the San Joaquin Local Health District for a permit to construct and ins#all the work herein described. 4 This application is made in compliance with County Ordinance No. 549. ° ------- -- �.. JOB ADDRESS AND LOCATION - - a Owner's Name ------•-- +�------------- ---------------------------------- Phone--2`-�-_0/-------- Address---- - --Z-9-------- ---- -------- ----------------------------------------------------------------------------------- -------- ---- Contractor's Name---At P-A---- _._ . '8 ------------------------------------------------------------ Phone-- '"" iii-_do --- Installation will serve: Residence'; Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ i I Number of living units: Number of bedrooms -R- Number of baths __I___ Lot size l__________________ 1 Water Supply: Public system ❑ Community system ❑ Private P§ Depth to Water Table ________ ft. l; Character of soil to a depth of.3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe Hardpan ❑ Previous Application Made: Yes ❑ N0 New Construction: Yes E] Nox 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---------------------- Disposal --------- -----_.Disposal Field: Distance from nearest well--____Distance from foundation------JV____-Distance to nearest lot fine-,:al e -------- Number of lines--------------- --_;:---_ __--Length of each line-------/,�Q-----�---_---Width of french-------��--------------------- es Type of filter material---- _______/ __Depth of filter material______ ____ -Total length-------- _Ao_'_------------------ 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 well_________________Distance from foundation------------------- Lining material________--___--_____________--__--_--. .1 ❑ Size: Diameter--------------------------------------Depth--------------------- -----------------------------Liquid Capacity----------------------------gals. Privy: Distance from nearest well______________________________________________Distance from nearest building____________________---.-.-------------- r ❑ Distance to nearest lot line--------------------------- ----------------------------------------------•---------------------------------f° Remodeling and/or repairing {describe)=-------------------------------------------------- --------------------------- ------------------------•---------------•---------------------------- -------------------------------••-•------•------------------•----------------------------•--------------------•-•----------------------------------------------------------•-------------------------------••---------------- a k ______________________________________________________________________________________________________________,_-_________-.______-__________-__________-_._______-_______________-_____________________-___________________._ 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)---P' '--- r - ----------- -------------------------------------------------- ( /or Contractor) ;r 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---- REVIEWED BY - - --- ---- ----------------------------------------- DATE BUILDING PERMIT ISSUED-------------- -- -------------------- -------------------------- DATE------------------------------- --------------- Alterations --------------- ---------- ---------------Alterations and/or recommendations-------------------- ---------- ---------------------------------------------------------------------------- ------------ ------------------------------------- -------------------------------------------- -•------------------------------ -----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------F } -----------------------------------------------------------:----------------------------------------------------------------------------------------------------------------------------------------------•------------------- -------------------------------------------- ------------------------------------ ------------------------------ ------------------------------- --------------------------- --------------------------------------- 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-9-2 8-51 Revised W-2100