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r APPLICATION FOR SANITATION PERMIT Permit No. ........_..._.....q. (Complete in Duplicate) _ _ Date Issued -_��___-�____J._� 1 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...___ Owner's Name----------------_------ - a Phone --------------------- Address... � Address------------------------ W, ----------- --- ., ' ------ ------------- ------ --• -------------------------------------------------------------------- ------------------•-- ----------------•------------- --• -•--•-- -- - -----...._.... Contractor's 'Name---------------------------------•-------------t --•-- Phone---- Installation will serve: Residence 9 Apartment House ❑ Commercial ❑ Trailer Court ❑ Mofel ❑ Other Number of living units: ________.Number of bedrooms ____ Number of baths __.I- Lot size - -- ------- --------------------- Water Supply: Public system Community system ❑ Private ❑ Depth to Water Table ______ ft. F Character of soil to a depth of 3 feet: Sand ❑ f. Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe Hardpan ❑ Previous Application Made: Yes ❑ No K New Construction: Yes W No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic fank`or cesspool permitted if public sewer is available within 200 feet.) p No. of compartments.-----------r-----._.size_ cX � ---Li :id clep h--.Mate aL---- ---------------------------------- �y $eTank: Distance from nearest well____�___-._.___Distan e fr fou atioquld depth----- `�IU--`-_-__Capacity_..._�6-_�--- Diis o I Field: Distance from nearest well_._______ .__Distance from foundation______ __ __` 1 -- �� ___.__Distance to nearest lot line__________ Number of lines----:-------- - --- - -------- g Len th of each line------------- a0 it ;i-----.Width of french ---------- Type of filter material_ ,�---Depth of filter material___.____��___ -Total length__________________,l�d --- ------------------- Seepage Pit: Distance to nearest well______________ _ ________Distance from foundation-------------------- to nearest lot line__________.__ *-- ❑ Number of pits----------------- --Lining material------------------------Size:.Diameter----------- ---------Dept h ---------------- -- ------------- Cesspool: Dista rice from nearest well-------- -----Distance from foundation------------.-------Lining material___------------------------.__.______- ❑ Size: D_iameter------•-------°° --------- ------De th- - Li uid Ca aci.t ,.,; 4h ;� - ---: _ q p y----------- gais. Privy: Distance from nearest well_________________________ ___________________:_Distance from nearest building ❑ .Distance to nearest lot line-------------------------------------------------- Remodeling ----------------- ----------------------------Remodeling and/or repairing (describe)-----------------------------------------------"------- -----------------•------•-----------------..---------------- ------------- ---------•--•--------•--•----------•-- ------------•--------------------------------- -------------- ----.---------- -----------------------------•-------------------------- ----------••------- -••------------------------------------------------------------------------------------------------------------------------------------------ -------------------------------------- - } --•------------•---- -------------------------•------ 1 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)--- .. - �. gid - --------------------- ' (Owner and/or Contractor) BY^ -----------------------1'_ ---•• ---------------------------------------------------------------------------------(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..---------- F r REVIEWEDBY -------- -------------------------------------------------------------- DATE BUILDING PERMIT,ISSUED------------------------------------------- ---------------------------------------- ------ DATE Alterations and/or recommendations:------- - - ------------------------ -----------------------------------------------•--- ------•------••------•-----•-- --•-----------------------•---------------------------------'-------------------------------------=------------------------ } -----------------•------------------- FINAL INSPECTION BY:: T ------- ---------------------------- Date 01- - --/ 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 t ES-9-2M I0-52 Revised W-2100 y