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�' APPLICATION FOR SANITATION PERMIT Permit No. ..•3-_3/ (Complete in Duplicate) Date Issued _______________________ Application is here'b'y`made to the San Joaquin Local Health District for a permit to cc#nstruct and install the work herein described. This application is made in compliance with County Ordinance No. 549. JOB ADDRESS AND LOCATIO ._a _ �t �<t• fid �m: _ _____ J ___.__ ._...____ .___--._._._.._ -------------- ---------- --------- _ __.___._. ____.___. .___-._._ t/. � . �.... Owner's Name Phone Address............ - �e<- . ------ Contractor's Name. `t` k�----- ----- �` -------------------------------------------------------- Phone--- ` 4 -- --- `- Installation will serve: Residence X Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: __f-_ Number of bedrooms __Number of baths _..ZLot size ...... _ __ ....s ----------------------- Water Water Supply: Public system ❑ Community system ❑ PrivatejK Depth to Water Table -------- ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe . Hardpan ❑ Previous Application Made: Yes ❑ No ❑ New Construction: Yes ❑ No ❑ 4, TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) tic Tank: Distance from nearest well_•______________•Distance from foundation-_______---__..-..Material___-.___________________._______-___-____--.___-. �&,*> No. of compartments--------------------------Size--------------------------------Liquid depth-------------------------Capacity----------------------- Disposal Fief Distance from nearest well-c577------Distance from foundation'_-------Distance to nearest lot line....... Number of lines--------/-------_ Length of each line__..�_�` ---------Width of trench_ Type of filter material.._ `/__± ____Depth of filter material____ _�__-__Total length___. ' ........ Seepage Pit: Distance to nearest well---------_------------Distance from foundation--------------------Distance to nearest lot line----------------- El Number of pits---------------------Lining material-_------.--------------Sizer Diameter--_----_-------------Depth--------------------------------- Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material__-____-_______-____-__-.__________._ ❑ Size: Diameter-------------------------------------Depth-------------------------------------- -------------Liquid Capacity- ---•---gals. Privy: Distance from nearest well-------------------------------------------------Distance from nearest building---------------___________-_-__-_-_.___- ❑ Distance to nearest lot line----------------------------••------------------------------.--------- Remodelingand/or repairing (describe):------------------------------------------------------------------------------------------------------------------------------------------------------- ---------------------------------------------------•---------------------------------------------------•----------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ --------------------------------------------- -----------------------•-------------------------------------------------------------------------------------------------------------------------------------------------- I hereby certify that ha' prepared this.application and that the work will be done in accordance with San Joaquin County ordinances, State laws,.an ru sand regulaityo`s of the San Joaquin Local Health District. A, (Signed) l `�"` -- ---- ------------------- ---- Contractor) .. y By: •----•------ ------------ = (Title) � _` � g _ (Plot plan, showing size of lot, location of system in re ion to wells, bumgs, etc., can be aced on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY------------------------------------------------------ DATE-------- --- . REVIEWED BY ------------------------------------- --• 1r-.S-�----- ---- - -- - DATE---------------- -•-- --------- ----------------------------------------------------- --- - BUILDING PERMIT ISSUED...................................................................................................... DATE------------------------- Alterationsand/or recommendations:---------------------------------------------------------------------------------- -------------------------------------------------------------------------- ---------------------------------------------------------------------------•--•----•----_.......----------------...---------•--...---•--•-•-•------•----------•-••-•••....................................................... ---------------- --------------------------------- ---------------------------------------------------------------------------------------------------•------------..............----------------------------------------- -------------------------------- ------------------------•------------------------------------------------ -------------------------------------------------------------------------------------------------------------------------------------------------•----------------------------------•---- ----------- ------- ----- . ---- ----------------- ---------- -------------- FINAL INSPECTION BY:•_______________ t ' �: ) + 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 10-52 Revised W-2100