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_ Y APPLICATION FOR SANITATION PERMIT Permit No.3.9------- ---- -------- (Complete in Duplicate) Date Issued?_Y_ Application is hereby Imad e 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---=--- •-------• . Ji� Phone = Address----- -400-0 f�----- 5y-'-------------•-----------••---- Contractor's Name----------------------- -- ----- Phone---- --------- Installation will serve: Residence Ig Apartment House F1Commercial E] Trailer Court E] Motell❑ Other El Number of living units: _�____ Nu`mber of bedrooms __Y Number of baths ____t Lot size ____f_�_----�1-------------------------- r Water Supply: Public system ,d& Community system El Private ❑ Depth to Water Table f+.4- Character of soil to a depth of 3 feet: Sand ❑ Gravel [I Sandy Loam ❑ Cla41oa flay ❑ Ado a Hardpan ❑ Previous Application Made: Yes F1No . New Construction: Yes ❑ No E] 0 TYPE OF INSTALLATION AND SPECIFICATIONS: eTallo septic tank or cesspool permitted if public sewer is available within 200 feet.) S n Distance from nearest well_________________Distance from foundation--------------------Material_______.______-"_.. ----- I —I No. •f compartments------- ------------------Size------------------------•------ Liquid depth - CapacitY I �IField Distance from nearest well-________________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 materia---- length----------------------------------------""----- Seepaa Pit: Distance to nearest well_- _____Distance fr m foundation_ r._____.Dist Distance to nearestTl t line_ _____ Number of pits--1.---- ------Lining material -- ---Size: Diameter_J- ------------Depth � --------------- Cesspool: Distance from _ .nearest well_________ ._____Distance from foundation______--------------Lining material_______.�-__________.-_----------- El 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): ---------------------------- ------ ------------------•••-----------------•---------•--•------------------•-----------------------------------• t ------------------ ----------------•--I------------------------------------ ---------------------------------------- ---------•----------------------•----------------- -------- -------------------------------- ------------------------------- I hereby certify at I have prepa d this app is tion and that the work will be done in accordance with San Joaquin County ordinances, State laws, an ules and gulations o e San Joaquin Local Health District.( ----- --------- Contractof)� - (Signed) ------- - -- I ------- --------------------- ----- ------ -- ---- -----(Title)- (Plot plan, showing size of lot, location of system in r ation t e s, buildings, a ., an be pl cod on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY--------------------------- --- • ------------------ DATE------------- REVIEWED BY DATE_ ----------- --- - ------------------ BUILDINGPERMIT ISSUED---------------------------------- --- ---------------- DATE------------------------------------------------------------ Alterations and/or_recommendations:--------------------------------------- --------------------------------------------------- ---------•------•----------------------------------•------------ ------------ ----•----------------------- ------------- ------------------- I -------------------------------••-------------------------------------------•--- I --------------------------------------- ---------------------------------- ------- -----------•-•----------------------- ----- e ---------------------------- FINAL INSPECTION BY:-------"' x -------------------------- Date - - 1# 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