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•� �-3 APPLICATION FOR SANITATION PERMIT Permit No. I in Duplicate) (Complete Date Issued .__... .... Application is hereby made to the San Joaquin Local Health District for a permit to construct an install the work herein described. This application is made in compliance with County Ordinance No. 549. JOB ADDRESS AND LOCATIO ------------- ----------- .. -• ..... -- •= ------------------- - Owner's Name............................... •--•---- •. ....... ------- - ----r .._. ------------------ ------------- Phone------------------------------------ Address--------------- •-••----•------- - ..-------ts- ---- ..... ....... ----. . .--- --- --- . .t Contractor's Name -' ¢ --- --- --W_ r hone. Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ M tel ❑ Other ❑ Number of living units: ________ Number of bedrooms A Number of hs ._- t size .___.._ _, ..,/__ __ _______________ Water Supply: Public system [I Community system El Private Depth to Water TablZZI-1.101t. 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 ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tank- Distance from nearest well-----------------Distance from foundation--------------------Material•_---___.-_____.-___---_________-__--_____-. "'"_ No. of compartments--- ----------- ----•-Size--------------------------------Liquid depth-------------------------Capacity-- Disposal Fi d: Distance from nearest well.6d--------Distance from foundation../.!J___.......Distance to nearest lot line__Cs_-__...... Number of lines.__ _ �j� Length of each line_ .Q.�___y____.Width of trench.._. _____________________ Type of filter maferiaL4.,_ __Depth of filter material___ .___.___Total length...____----________________ ep Seepage Pit Distance to nearest well--- 6.�__._____Distance fr m f ndation .Q.�___.Distance to nearest lot line----6-___.. ' Number of pitsj;_ .�.___---Lining material..* t-.Size: Diameter.`0............Depth-_--- .--_-__---- Cesspool: Distance from nearest well-----------------Distance from foundation-----.--------------Lining material------------------------------------ n _.__ _--_----__-.--_____---._-__- ❑ Size: Diameter--------------------------------------Depth-----------------------------------------------------Liquid Capacity--------•----•--•-----•----gals. Privy: Distance from nearest well-------------------------------------------------Distance from nearest building-___-._-_-___--___:--_-____-_.-_-_.-__-.-. ❑ Distance to nearest lot line----------- – -----------•-------- ----------- m' Remodeling and/or repairing (describe)------- --------------- ------- ------ •---- ...•- - ------------------ ........ ----------------------------•----------------------------------------- -- ............. --------------------------------- ----------- --------------------------------------------------- -- ------ __ __. .__._.--- ....................._-______._-_-___-._.-_...... I hereby certify that I have prepared this application and that the work will be done with San Joaquin County ordinances, State I s, and rules and r ulations of the San Jo quin Local Health 'strict. • r (Signed) d- --- ! "'` . ..... ( ran or Contractor) �s (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--------3/_r - -� REVIEWEDBY--------------=-------------------------------------------------------------------------------- •------------------- DATE-----------•--------------------------------------------- BUILDINGPERMIT ISSUED...................--------------------------------------------------------------------------------- DATE------------------------------------------------------------- Alterations and/or recommendations:----------------------------------------------.......... --------------------------------------------------------•---- -------------------------- ------ ------------------------------------------------------------------•-------------------....--------- ---------...---------------------------•------------------............................................................. --------------------------------- ---------------------------------•--------------------------------------------------------------•----•---------------------------------------------------------------------------------- - ----------------------------- --- --- ------- ----•------- ------------------------------- -------------- ------------------------------------ FINAL INSPECTION BY-------------- -- l_...... Date----------- �-- - -------- ------ ------ ------ SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Street 614 North "C Street Stockton, California Lodi, California Manteca, California Tracy, California ES-9-2M 10-52 Revised W-2100