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APPLICATION FOR SANITATION PERMIT Permit N . c=�_!_--•`� _ (Complete in Duplicate) Date Issued Application is hereby made to the San Joaquin Local Health District fora permit to construct and •install the work herein described. This application is made in compliance with County Ordinance No. 549. JOB ADDRESS AND LOCATION-----------� I _' �r --- --------------------------------------------- Owner's Name--------------------- � Y -. - _ Phone - ------------------------------------ ------------------ Address------------------------------------------------------- ----------------------------------------------------------------------------------------------------------------------------- Contractor's Name--------------------------------------------- f---------------------------------------- -------------------- -------------- Phone Installation will serve: Residence Apartment House 'El Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: -------- Number of bedrooms _%3__ Number of baths __ __ Lot size ____ _ ..__i__-__-_-_-____.---_ Water Supply- Publics stem Community system ❑ L 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 ❑ No New Construction: Yes1k, No [] TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) I i Sept> ic Tank- Distance from nearest well -------Distant from foundation_____1d__-____.Materi No, of compartments_______ ------Size-----4.X+' x =Li uid depth acit __________ ----------- D ____ { q p p y - Di os I Field: Distance from nearest well__.-_____.DEstance from oundation----________-------Distance to nearest lot Number of lines-2-01-_�'-^'4 Length of each line___-_I ---------------------Width of trench________�_�~/1 Type of filter material-�-lav--A,, Depth of filter material---------��__------Total length-------------Li? -------------------- Seepage Pit: Distance to nearest well----------------------Distance from foundation-------------------.Distance to nearest lot line__--_-____-_-__-_ Q } ❑ Number of pits-----------------_----Lining material-----------------------Size- Diameter------------------------Depth------------------- --------------- lO" Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material------------------------------------- {Ill ❑ Size: Diameter-------------------------=------------Depth-------------------------•---------------------------Liquid Capacity----------------------------gals. Privy: Distance from nearest well ------------------ from nearest building__--_--________-_-__-_-_._ ---------------- ❑ Distance to nearest lot line----------------------- ------------------------------------------ Remodeling and/or repairing (describe):__________------_---------------------------------------------------------------------------------------------- ---------------------------------------- --------------------- ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------•---------------------------------------- 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. � � 1 (Signed)_ 4 � ___-- - .- _Y-U --_ - --------- _____________(Owner and/or Contractor) sY:---------------------------------------------------------------------- -------------------------------------------------------------(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___-__--_-____ REVIEWEDBY ----- -------------------------------------'--------------------- DATE -------------------------------------- BUILDING PERMIT ISSUED-------------------- --_-------------------- ------------ DATE-- ------------------------------------- --------------- Alterations and/or recommendations:---- f -�--- -- -----^-- _-- _-- ----it__ -------1- - r_1J_J - - -3 ------------------------------------ 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 5-51 Revised W-2100