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Permit No. APPLICATION FOR SANITATION PERMIT U� ---3 a._�._ N r+�• (Complete in Duplicate) — Date Issues! --- - _ ----. -� 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 �f_��6��---- •---•--- t_ r —=z---------------------------------------------------------------------------- Name_ /J C {_.. ---------------------------- --------------------------------------------- Phone-n,------------------ Owner's _ i r Address------- �-w----------� -----=a---�-*��-�- -- -z�-�----=-=� -'�--�--------- ------------------------------------------•-- t Contractors Name �� ----- ---------------------------------------------------------------- Phone---- • 2 _ ' Installation will serve: Residence-,,< Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other/❑ Number of living units: ---1--- Number of bedrooms-_ Number of baths _- __ Lot size..'! '-_ -------- 7---•--------------------- \1 Wafer Supply: Public system X Community system ❑ Private ❑ Depth to Water Table -------- ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe[ Hardpan ❑ Previous Application Made: Yes ❑ Nor New Construction: Yes ❑ NoIN i 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 __-_______-----_____------_--_-_--_----------. / y No. of compartments--------------------------Size--------------------------------Liquid depth--------------------------Capacity----------------------- - D�dsp,,'?lField Distance from nearest well-----------------Distance from foundation--------------------Distance to nearest lot line--.----_.--..--_. � ❑ Number of lines-----------------------------------Length of each line------------------------------Width of trench----------------------------------- f 5 / Type of filter material------------------------Depth of filter material-----------------------Total length------------------------------------------ Seepage Pit: Distance to nearest well-_1F9 U_.,_-_-Distance from foundafion----f1 Distance to nearest lo�ne_�...-_._. �` Number of pits------ ------------Lining material- r •_�_!.fSize: Diameter_-- -_-_-__-_---_Depth____-- '�� ,r'" 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---------------- - - -- ---------------------------- Remodeling and/or rep irm escribe)•- .._ a .__�__'-�- ------ -- �? -- '" - ----� "_.Z---.-•.. r- d _ .. ---------- -" � -�a2� r. nr , _ ----------------------------------- ------------------------------ =� ----------------- ----- -- ----------- --------------------------- here y cern +hat I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, S e laws, a ;"rule and regul tions of fhe..San 3oaquin Local Health District. (Signed) .l _ -------- _ ;: -- Owner and/or Contractor By------------- - - -x r----- '' =-- ---- --------------------------------------(Title)- � , 4 •r'`t-r." (Plot plan, choly rig size f lot, I 'at- n 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-----------------Rta Alterations and/or recommendations:------------------------------------------------------------------------------------------------------------------------------ ----------------------------------------------•---.------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ----------------------- --------------------------------------------------------------------------------------------------------------------------------•------------------------------------------------------------------- ----------------------•------•------------•---••----•---------------------------------------------------------- ----------------------------------------------------------------------•------------------------------------- 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-9-2M 8-51 Revised W-2100