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b APPLICATION FOR SANITATION PERMIT Permit No. 3 __.:.______� �.� (Complete in Duplicate) Date Issued 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 No. 549. JOB ADDRESS AND LOCATION. ------------------------------------------ --------------------------------------------- Owner's Name------------------------------- Phone-------------------- Address ----------- ---------- ------------------------------------------------------------ -- ----------------------------------------------------- Contractor's Name - •. ---------------- Phone _______________________ ___ Installation will serve: Residence partment House ❑ Commercial ❑ Trailer Court E] Motel E] .Other ❑e Number of living units: __� Number of bedrooms __1____ Number of baths -----[-_ Lot size Water Supply: Public system ❑ Community system ❑ Private epth to Water Table -------- ft. a Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe an ❑ Previous Application Made: Yes ❑ No New Construction: Yes I.'R-o LJ _ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sgwer is available within 200 feet.) Septic Tank: Distance from nearest well 4 ! Distanc, fro fun ation------ Materiel----------- ------ S� �----- - ---- ------------- .No. of compartments______ __________Size__.___ _kc -!______Liquid dept__________ Ca acit y-------- isposal Field: Distance from nearest well__ 70_____ Distance to nearest lot line_____ ,(� .Distance from foundation___ Number of lines----------------� Length of each line------------ ,�, ----- --1�--- Width of trench_--__-k ______________•-__-_-- Type of filter material------- .Depth of filter material--------- `--Total length__..________,_ r Seepage Pit: Distance to nearest well-----------------------Distance from foundation--------------------Distance to nearest lot line_______-_____-___ ❑ Number of pits----------------------Lining material-----------------------Size: 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_______ ---------------------------------------------------------------------------------------------- Remodeling and/or repairing (describe):------------------------------------------------------------------------- ---------------------------------------------------------------------------------------------------------------------- -------------- -------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, Sta a laws, and rules and regulations of the San Joaquin Local Health District. (Signed)- ---- --------- ---_ r ___-- ------------------(Owner and/or Contractor Title B ------------------------------------------- V---------------------------------------------------------------------------------- (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___-_-______________- +— ' *-*f----- DATE r� -L�- ---------- ---------------- REVIEWED BY - - DATE_ BUILDING PERMIT ISSUED----------------------------- ----------------- Alterations and/or recommendations:--•----- ----------------------------------------------------------------------- DATE------------------------ -------------------------------------•---------------------- ------------------------------------ - ----------------------------------------------------- -------------------------------- FINAL INSPECTION BY___________ ______ ------------------------- ----------- Date--------------�/ �-�_--��---- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Street Stockton, California 814 North "C" Street Lodi, California Manteca, California Tracy, California ES-9-2M 8-51 Revised W-2100