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FOR OFFICE f-------------- 9 -------------------------------- -------------------------------------- APPLICATION FOR SANITATION PERMIT Permit No. ..... .._....T I -------------------------------------------------------- (Complete in Duplicate) Date Issued .______ ___ f --------------------------------------------------------- ,This Permit Ex ires'l Year From Date'lssued 5 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 N 549.,: , JOB ADDRESS AND LOCATION -- ------- ------------------------------- Owner's Name-------------------------------- =_f-------It ----------------------------------------- ---- --- Phone....---- -.--_--------- Address...................... �r�' ? Contractor's Name- -- -- ---- -- - •-•--- ---------------------- ------------------------------------------------------------------------------------------- - Phone-----_---------------- ------= � w ' _ Residence �iiartment 'House, , r., Inst dation well serve:, � �❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ l i� Number of living units. _.!__-_ Number of bedrooms .�. Number of baths _�----- Lot size � X`161_-a----------------------------- Water Supply: Public system Community system ❑ . Privajte ❑ Depth to Water Table�Q-- ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel�❑ �nd Loam ❑ Clay Loam El Clay ❑ Adobe ardpan 11 Previous Application Made: (if yes,date--..--.--- .---.) No New Construction: Yes ❑ No 5�--l<HA/VA: Yes ❑ No TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) S Septic Tank: Distance from nearest well--------------i-"Distance from foundation--------------------Material _-----___--_-._-._--_-_--_-_------.__--_--__--- No. of compartments--------------------- Siie----------------------------------Liquid de th- Capacity----------------------- Disposa Feld: Distance from nearest well Distance from foundatior}�_0__ -----.Distance to nearest lot line-5-------_-__----- [ Number of lines_______________J/�__.__�_---_Length of each line_.._.__._. ,f_4. Width of trench .- .._.____._.____.___ Type of filter material-_---_____-__�-----_-__-Depth of filter material-------/__�____=_Total length-------';J��t_ -------------------- Seepage P' : . Distance to nearest;well-__"'_~Distance from foundation__()-�.__�istanjq to nearest of line- _---_._ NNumber of pits._-.----__]-.---_---Lining material__X'd_.r._a[---.Size: Diameter _t�___--.__-_Dept h_s�-�------------------- Cesspool: Distance from nearest well----------------:Distance from foundation--------------------Lining material----._._--.-_-,---------------------- r [❑ 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 i I t � ________ __________________________________ __________________________________________________________________________________________________________R ___________________________________________________________________ I hereby certify that Fhave prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State laws, a d r les and regula 'n sof the San Joaquin Local Health District, ; c-. 4 (Signed)--------------------- 41 '"/_---------- S Owner and/or Contractor 1 By:------------------------------------1 -- ------------ L �------------------------- ------------- {Ti+le) G./[�'"-�1 -�^... 1 --------- ------ (Plot plan, showing size`of to cation of system in relation to wells, buildings, etc., can,be placed on reverse side). FOR EPARTMENT USE ONLY �l APPLICATION ACCEPTED BY------- -- - - -------------------- - - ---------------------------------------- DATE REVIEWED BY ------=-- DATE --••-- BUILDING PERMIT ISSUED-----•-------------------- _ ' # -----._ DATE------------------------------------------------------------- Alterations and/or recommendations:--- --- ---------- - ------------- ---------------------- -------------------------------•---•-----•---------•--------------------------------------------------------------------------------------------------•--- ••--------._. •----------------- f _ ----------------------------------------•--------------------•-------------------•-----•----------•------ -----------------------------------------------------------•--------------•-------------•---•-•-•----------------- •------•-----------•--•-------------...-------•------------•-------=----------------------------------------------------------------------•--------------------------------------------------- -•---- ------ r FINAL INSPECTION BY ,. - ----- - r Date.-� =� ------------------------------------------ SAN --------------------------•---------- SAN JOAQUIN LOCAL'HEALTH DISTRICT 130 South American Street 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,California Manteca,California Tracy,California E9-9 REVISED a-59 F.P,Pp,,ZM 5-5P