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APPLICATION FOR SANITATION PERMIT Permit No�_ .__.?... .... a (Complete in Duplicate) Date Issued, _7___ ___. _ 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 o. 549. C _ I JOB ADDRESS AND OCA I N I -- --- --- ------------------------------------I--- -- ------- -------- Q�r 9 Owner's Name ---- "'a Phones -._�- r ------------------------------- ---- Address------------------OH93.1....... -------------------------------------------------------------- -••-----••--------- ---------------------- - - Q Contractor's Name------- •--- # '`T` -------------------------------------- -------•------------------------------------ Phone%-�---- Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel L) Other ❑ Number of living units: ---/_ Number of bedrooms =?-__ Number of baths _L Lot size _. __X led-__ ---yl Water Supply: Public system Eil�Community system ❑ Private ❑ Depth to Water Table _yrtt. Character of sail to a depth of 3 feet: Sand Gravel ❑ Sandy Loam ❑ Clay Loam ❑, Clay ❑ Adobe Hardpan ❑ Previous Application Made: Yes ❑I No ✓[ New Construction: Yes ❑ No TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 fee+.) i .. Septic Tank: _,.- Distance from nearest well-----------------Distance from foundation--------------------Materiai---___----_.---._____-_----_______-__._---__._. ❑ No. of compart�encs--------------------------Size------------------------•-------Liquid depth----------- ---- ---- ----Capacity------- ---•----------- G Disposal Field: Distance from nearest well-_ --------------Distance from foundation-----------------_Distance to nearest lot line_-__---_----____- ❑� Number of linest--------------------------------Length of each line--------------_----------------Width of french--------------_-_--------_-------- Type of filter material----------- -----------Depth of filter material-----------------------Total length--:-------------------------------------- Seepag Pit: Distance to nearest well------ �_-_-_-.-Distance fro fou dation------ .,.___.Distance to nearest lot ii �____C .-_-_- [y Number of pits_____,______________fining material__ _ _r .Size: Diameter__._'f� .��____._Depth_-_-O'� ____-____._______ UJ Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining ❑ material__.._--_..-.---.---_----..__--.-_---_. Size: Diame#er--------------------------------------De th----------------------------------------------------Li Liquid Capacity -- --- - ---------- als. Privy: Distance from nearest well ------------------------------------------------Distance from nearest building-- -----.---- ❑ r Distance to nearest lot line--------- --------------- - -----------------------------•-------------------------------------------------------------------- Reme)eling and/or reps'ring ( scr'b ' J. U-- -- -�-,� •�� _-- - -------------- = ---- I I I hereby certify that-I have prepared this applica+ion and that the work will be done in accordance with San Joaquin County ordinances, State is and rules and regulations of the San Joaquin local Health District. .: _ �r - = - and/or Contractor (Signed)-------- i / ) BY: •--------------------------------------------------------------- (Ti+le) ---------- ----- ------------- - ----------------- (Piot plan, showing size of lot, location of system in relation to wells, buildings,.etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY Ii APPLICATION ACCEPTED BY-- :----------------------------- - ------------•----------•-------------------- -------- DATE ---------------- ----------------------------- REVIEWEDBY--------------------------------- ' --- -- ----------------- ----- ---------------------------------------- DATE-----,3------- --------------- -------------------------- BUILDINGPERMIT ISSUED-------------- -- --------------------------------------------------------------------------------- DATE-----��_ .__----------------------------------------------- Alterations-and/or recommendations:--------------- --------------------------------------------------------------•------------------------- --------------------------.-._.....-..--------------------- ----------------------------••------- ---------------------------------------- -------------------------------------------------------------------- I 1 ' ------------ --'-- ----------------------------------------------------------------------------------------- -- --------------- 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-2300