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�,� 3 APPLICATION FOR SANITATION PERMIT Permit No. (Complete in Duplicate) Date Issued Application is Jreby 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 L CATION----___lvU_ - .- � s - -- ------- --------- ----------- - ----- ---- - Owner's Name-----/ -..- J -------------- Phone- - ------------------------- -- Address----------------------------------------- Contractor's Name----------------------- ------------------------------------- ------------------------------------------ Phone-- ------------------------.------ Installation will serve: Residence partment House ❑ Commercial ❑ Trailer Court ❑ Motel _ Other � ` - Number of living units: ___ ___ Number of bedrooms___�__ Number of baths --/-- Lot size ____________ ___ _____... Water Supply: Public system ❑ Community system Private ❑ Depth to Water Table --- ---- ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam x Clay ❑ Adobe ❑ Hardpan ❑ Previous Application Made: Yes ❑ No_'O�__New Construction: Yel�nl No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) S ptic Tank: Distance from nearest wellce rompfoundation-------------------Material_____--_______----_._-_----__-----.--------.-. No. of compartments--------------�----J-----------Size-----------------------•--------Li�uiddde f -------------------------Capacity----------------------iprosal Fier Distance from nearest we€I_I-1�.��Distance from foundatio _--- ...Distance to nearest lot li e____ _ Number of lines---..._.-__ .. Length of each line-3s" -_.-.Width of trench.-""I- Y Y L r �------------ Type of filter material__-T_r__�_�__Depth of filter material_..__ ____________Total length Pit: Distance to nearest well_--_-__--=----------Distance from foundation--------------------Distance to nearest lot line--------------- F1 Nvrber ofpits-.. m-- - Cesspool. Distance from nearest well----------------- from foundation--------------------Lining material___-__--------_-_.------_--_-.----__- ❑ Size: Diameter----------------------------------_-Depth-----------------------------------------------------Liquid Capacity-------------------------- -gals; h Privy: Distance from nearest well------------------------------------ ------Distance from nearest building--------------------------------------- ❑ Distance to nearest lot line--------- -------------------------------------------------------------•----------------------------•--------- --------------- ------------- Remodeling and/or repairing (describe)---------------- ---------------------------------------i --------------------- -- -•--------------------------------------------------- ------------------------------ ------------------------------------------------------------------------------------------------------------------------------ --------------------------------------------------------------- w --••-------------------------y-------------------•-------•--------------------------------------------•-•-•--------------------------•-------------------------------•-------------------------------------- ------------------------------------ -------------------------------------------------------•----------•-------------------------------------------------------------------------•--•-----•----------------------------- ---- I 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 an re lations of the San Joaquin Local Health District. -----------------------------'------- - --- --------------------(Owner and/or Contractor) (Signed)--------------- ��` --- - - -- --------------- - - -- - By:--------------------�/--------------------------------------------------------------------------------------------- t-----------(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------ ------ -111-7-----`----& ,. REVIEWEDBY-------------------------------- --------------------------------------------------------------------------------------------- DATE------------------------------------------------------------ BUILDINGPERMIT ISSUED-------------------------------------------------------- ---------------•----------------------------- DATE-------------------------------------------- --------------- Alterationsand/or recommendations------------------------------ ----------- ----------------------------••--•------------------------------------------------------------------------------------ ----------------- ---------------------------------•-------------------------------------------------------- ------------------------------------------------------------------------------------------------------------- ---------------------------------------------------------------------------------------------------•---------------------------------------• --------------------------------------------------------------------------- ------------------------------------ ------------------------------------------------- •-------------------------------------------- -------------- ---------------------------------------------------------I---------------- ----------------- ----------- --------- ----------------- ------------------------- --------------------------- -------------------------------------•----- ----------------------------------------------------------------- �s , FINALINSPECTION BY-----------------------�---------------------------------- Date---------i---------- --•�, ^ -- ---------------------------- 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 10-52 Revised W-2100