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APPLICATION FOR SANITATION PERMIT Permit No. -.`�__.. (ComPplete in Duplicate) / fl � Date Issued -------/ "9 �5� Appllicalion is hereby made to the San Joaquin Local Health District for a permit to onstruat and install the work hefein described. This application is made in compliance w-K oun Irdi�nce No. 549 y JOB ADDRESS AND LOCATION---- ---- _________ w - ------------------- Owner's Name----------------•------- — lam.. R _-` f`_ . -- ---- --- -- -------- ---------------- Phone------- ------------------- Address---------------------------------------------------•---� ---;,-Z-5-- Q' �y� - - I Contractor's Name------------------------- ------------ -----------�--- �------- ----- -------------- Phone---- -y�� -----". Installation will serve: Residence X Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ i Number of living units: _- Number of bedrooms ___Z.._ Number of baths _y_ Lot size -____ _�__ _1�___/_ ,__. ______________ w { Water Supply: Public system Community system ❑ Private ❑ Depth to Water Table ________ ft. I Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ ClayLoam ❑ Clay ❑ -Adobe K Hardpan ❑ Previous Application Made: Yes ❑ No ❑ New Construction: Yes ❑ No ❑ (\� TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) tic Tank: Distance from nearest well________________Distance from foundation--------------------Material________________________________________--____(17 . [ t.,-s`.--•a No. of compartments--------------------------Size-------------------------------Liquid depth--------------------------Capacity----------------------- Disposal Field: Distance from nearest well_-_Distance from foundation_�.Z---�---.Distance to nearest lot Number of lines_______ ------j----- Length of each --------------"Width of trench- ------------------- Type �-------`--y- -------------- Type of filter matrial.. _ '�-- -- . p _____________________- __e . �___-__Depth of filter material------/9.. .___-_Total length----- Seepage Pit: Distance to nearest well----------------------Distance from foundation--------------------Distance to nearest lot line----------------- Q` El Number of pits----------------------Lining material----------_------------Size: Diameter------.-----------------Depth--------------------------------- Nr� Cesspool: Distance from nearest well-----------------Distance from foundation__________________.Lining material-------------------------------------- V► ❑ Size: Diameter------F-------------------------------Depth------------------------------------------- ------Liquid Capacity----------------------------gals, Privy: Distance from nearest well---------------------------------------------------Distance from nearest building_________________________________________" ul ❑ Distance to nearest lot line--------------------------------------------------------------------------------------------------------------------------------------------- 4 Remodeling and/or repairing (describe):--------------------------------------------- ----------------------------------------------------- --------------------------------------------- - �+ -----•------•----••--------------------------'--_-------------•-------•----- ------------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 law nd rules and regulations of the San Joaquin Local Health District. i -------------------------------------------------------- --------- - - (Signed) ` " r�'"°------ . � * Contractor) By---------- ---- - ----- - --------- ---------------------------------------------------------- ------------------------- (Plot plan, wing size of lot, locatia of sys+em irirela•tion to wells, buildings, etc., can be pal ced on reverse side). FOR DEPARTMENT USE ONLY y APPLICATION ACCEPTED BY---------- = 2-'- -------------------------- DATE-----------� . ` REVIEWEDBY--------------------------------------------- ------------------------------------------------------------------------------- DATE BUILDING PERMIT ISSUED---------------------------------------------------------------------------------------------------- DATE------------------------------------------------------------- Alterations and/or recommendations:- `---------------- ------ --- -------------------- -------------------------------------------------------------------------------------- ---------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------- y ---- -- ----------------------------------------------------- ----------------------------- --------------------------- ------------------------------------------------------------------------------------------------------------- FINAL INSPECTION BY----------------- - ------------------- Date------------- f-1_017--AL/------------------------------- y SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Street 914 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California ES-9-2M B-51 Revised W-2100 `^