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APPLICATION FOR SANITATION PERMIT Permit No. 3 ./._... (Complete in Duplicate) r(, Date Issued Applica+ion is hereby made to the San Joaquin Local Health District for a permit to construct and install the wor her scribed. This application is made in complier ith Count Ordinanc�No. S49. LOCATI } - ------------------------------------------------------------ --------- JOB ADDRESS A ------------------------------------Owners Name----- -- ---------- --••-•----- • -- ---------- -----:---------------------- --- ---- ----- Phone--------------------....--------•--- Address. '•-` -----------------------------...... --------------------------------•-•----•------••----------------------------------•----- Contrac ' Name----- -------- --------------------•--•-•--------------------------------------•------------------------•----- ------ Phone----------------------------------- Installation will serve: Residence] [Apartment House E] Commercial F] Trailer Court ❑ Motelr [I of f ❑ Number of living units: _1____ Number of bedrooms __ Number 'baths )---- Lot size __'. x ' __ Water Supply: Public system El Community system El private [Depth to Water Table r�i�_ ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Lo;�gNo Clay Loam QZClay E] Adobe E] Hardpan E]Previous Application Made: Yes ❑ No EB/ New Construction: Yes ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: - . , (No septic tank or cesspool permitted if public fewer is available within 200 l!feett,) ,� Septic 'ank: Distance from nearest well-IJ-0 fjom faun tion_/ --------- all_` .-�Y_____________________ y� -Ca acit No. of compar#mems------------------- ------Size(ll_ _ ------------------Liquid+�de�p�h,-n- - ----- -----___-- p y____�.. .' Dispos I Field: Distance from nearest well o-p+_Distance from foundation - rim" _.E'stance to nearest lot ii e.-- :--I , _. l = - Len Length of each liner`_ d_�____- ..Width of french------- �� -- rZ Number ol lines---I-----•'- r----- -- -- ------------• "') Type or filter mater' _ - th of filter materia!_.____�_ ________-Total length_______ _______________________________ Seepage Pit: Distance to nearest well.. -------- rom foyndation-_ ,1'__�_-_-_.Distance to nearest lot line__------- -_ p' W Number of pits._bs______________Lining 'material_ __-____.-.�_ __Size: Diameter--------q_--.-_-----_ Depth r• Z i Cesspool: Distance from nearest well-----------------Distance from foundation___-----------------Lining material------------- --_----_____--_-______. ❑ Size: Diameter------------------------ - ----Depth----------------------------------------------------Liquid Capacity----------------------------gals. Privy:_. .Distance from nearest-well-------------------------------------------------Distance from_nearest-build ing-_--------------..:__- z- ---.� [] .Distance to nearest lot line_____"" -'-"""-"T__.�' 1 3 Remodelingand/or repairing (describe):------------------------------------- -------------=----------•-------------•-----------------------------••-------•-------------------------------- ---------------•----•-•---------------•-------------------------•---------•--------------------------------------------------------------•-- -------------------------------------•----------------------------- ------ _. __________________________________________________________________________________________________________F_____..._«.__________-_-_---_-__.__________--_.___-_-__---.____________________-___---______._________.__.__-_- I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances,•St ate laws, and rules and regulations of the San Joaquin Local Health District. (Signed).... ter_ r._---- - - - -- -- - - - --- --------- ----------------''-------------------------------------------(Owner and/or Contractor) 6 . - -------------------------------------------------- R (Titley_)_ w y•---------------------------------- --------------------------------- --------------------- -------•----- -- (Piot .plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). 3 FOR DEPARTMENT USE ONLY APPLICATIONACCEPTED BY--t --------------=---------- ----- ----------------------------------------- DATES------------------- ---------------•------------- REVIEWED BY------------------- ------------ --------------- ------------------------- ------------ ---------- --------- DATE_�=- BUILDINGPERMIT ISSUED---- -------------------------•- -----------t "----------------------------------- DATE-------T--------------- Alterations and/or recommendations_______________: 1-- -----------_-__- _'. --------------------------------------- -------------------- --------------------------- --- - ---------•-------- ------------- _ �. c FINAL INSPECTION � •----- Date---/-7-- � ---- - ---- i ----------------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Street 814 North "C" Street S+ock+on, California Lodi, California Manteca, California Tracy, California ES-9 ,x5446 ATWOOD t