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72_ APPLICATION APPLICATION FOR SANITATION PERMIT Permit No. _ ............. v �- 1 (Complete in Duplicate) • � Date Issued ........ . ...... Applica+ion 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-----a,/. � Owner's Name G ------------ ----- Phone ---------- ---------- - ••-••--- Address ------------------•--------------•-------------•------------•---- -----------•--- `-�� Contractor's Name------------ ----- -- - ---------- Phone,l4a.4le6� 6 Installation will serve: Residence gi—Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: _�___ Number of bedrooms ---/- Number of baths .../ Lot size -----------8 .................... Water Supply: Public system [Community system ❑ Private ❑ Depth to Water Table A14- ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe B-*�Hardpan ❑ Previous Application Made: Yes ❑ No ®/Rew Construction: Yes RJ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) S tiE nk: Distance from nearest well_______ _______Distance from foundation..............------Material------------------------------------------------- No. of compartments------------ =--------Size................................Liquid depth--------- ------Capacity---------- •--------- D' osa 'e d: Distance from nearest well-----------------Distance from foundation--------------------Distance to nearest lot line................. Number of lines-----------------------------------Length of each line------------------------------Width of trench----------------------------------- Type of filter material-------------------------Depth of filter material------------------------Total length.......................................... _ Seepage Pit: Distance to nearest well -_-___Distance from foundation....410......_.Distance to nearest lot line___ao .1...... OQ 2r Number of pits----- --------------Lining mate ria .Size: Diameter___L3��----___-Depth------1021.............. 6 Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material.................._......_............ 6 ❑ Size: Diameter-------------------------- -----------Depth----------------------------------------------------Liquid Capacity--..........................gals. Privy: Distance from nearest well-------------------------------------------------Distance from nearest building-------------.------..................... ❑ Distance to nearest lot line--------------------------------------------------------------•-•---•----•-------------------------------•-----------•--------------------- Remodeling and/or repairing (describe):-------------------------------------------------------------------------------------------.._..-----------------•-•-•••----•----•---•----•-•--•--•----• ---•-------------------•----------------------•-----------•-----------------------------------•---------•---•--------------------- ---•--------------••-•------------•---------------•--------••-•--------------•-•-.----- -------------------------------••----------•-•-•--•--••••--•-----•-••--••-••-----•------------•-------•-----•--•-•-•••••--•--••---•------------------•-=--------------------------------•-----------------------•------------ I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, S to laws, and rules and regulations of the San Joaquin Local Health District. (Signed)---- ---------------------------------------------- �wnand or ContractorBy:•----•......•-•-••--••-----•••• -----l '-------------------------------------(Title)--- - ,�G��l--. (Plot plan, showing size of lot, location of system in ation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY---------------------------------------------------7-�.......--•------------------- DATE----------- 'jIJ S REVIEWEDBY------------------------------- -------------------------------------------------------------------------------- DATE............................................................. BUILDING PERMIT ISSUED------------------------------------------------------------------------------------------------------ DATE-------------------------------------------................. 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 Revised W-2100