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,� ►� //7 2-- APPLICATION APPLICATION FOR SANITATION PERMIT Permit No. _ o 3� (Complete in Duplicate) 9 . f_ r 1 j Date Issued _____ _.__� __Al replication is hereby made to the San Joaquin Local Health District for permit to construct and install t work a P s II he herein described. This application is made in compliance with Co O ince No. 549 ll y i JOB ADDRESS LOCATAON- !-_1 __ ------ --------- l Owner's Name_____ ____ - - -- --.�t.; � - - -- ------- - --------------------- -------------------------------------------- Phone- --- Address---_ s__- -- Contractor's Name--- -------- ------ ------------------d------------------------------------------------------------------------------------ Phone----------------------------------- Installation will serve:- Residence .Apartment House ❑ Commercial ❑ Trailer Court ❑ . Mot I [❑ Other Number of living units: __�__- Number of bedrooms _ _ Number o aths ---/-- Lot size _ __ e__ __I_-! _______________ Water Supply: Public system ❑ Community system ❑ Private Depth to Water Table -------- ft. [:]Character of soil to a depth of 3 feet: Sand Gravel Sandy Lo;�WNo Clay Loam E] Cay ❑ Adobe Hardpan El Previous Application Made: Yes ❑ Nog Sand Construction: Yes ❑ y TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) I�N epf c T k: Distance from nearest well--�---_--_____Distance from foundation-------------------.Material----------------------------------------------------- No. of compartments--------------------------Size---------------------------------Liquid dept ------------Capacity---- 6 1: Dispos i-Field. Distance from nearest well__-__Distance from foundation-- Distance to nearest lot if:,�:� Number of lines_---_--____ _ _ __ ength of each line_____-_CQ:- Width of trench_______�____ _• TF- I Type of filter materia ________°__ _: _. epth of filter material------1-6- _Total length---------�_�----------__________ � Seepage Pit: Distance to nearest well---------------------- from foundation_________.._______-.Distance to nearest lot line----------------- ❑ Number of pits----------------------Lining material-----------------------Size: Diameter-----------------------Depth---------------------_----------- Cesspool: Distance from nearest well________________Distance from foundation_-_______________.Lining maferial`__________________________--..I—— ❑ Size: Diameter--------------------------------------Depth----------------------------------------------------Liquid Capacity----------------------------gals. i Privy: Distance from nearest well_____________________-_____-__________--_---_Distance from nearest building------------------------------------------- ElDistance to nearest lot line-------------------------------------------------------------------------------------------------------------------- Remod nd/or�r,�painng (descri e)= -- - --------'--•-•--•------•--•-------------------------. I --- ---•-- �= ------- '- -t _ .......... ----- •---------- -- I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County i ordinances, St a a law—s',% and rules^and regulations of the San Joaquin Local Health District. (Signed)--- - � ! ----------- r_=-•------ ----------------------------------------------------------(Owner and/or Contractor] „3 gy:------------------------------ ------------------------------------------------------------------------------------------(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 13 _ -------. - -------------------------------------- DATE-_ ---------------------------- -- -- -- -- - REVIEWEDBY ------------------------------------- =----------------------------------- DATE- - ----••---•-------------------------------- BUILQING PERMIT ISSUED----------------------------------------------------------------------------------------------------- DATE Alterations and/or recommendations------- -----------__________ e - ------------------------------------------------------------------------•-------------•------------------------------ -----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------•-- ----------------------------------•------------------------------------- ------------------- -------=---------------------------------------------------------- ----------------------------------------------------------- FINAL INSPECTION BY_______________ _ ____ ____ ______ ___ -- Date # ---- r SAN JOAQUIN LOCAL HEALTH DISTRICT a 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-2i00 E