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APPLICATION FOR SANITATION PERMIT Permit No.CS;q--3_./_-__4 (Complete in Duplicate) Z� Date Issued _�_ __7/�_- 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 finance No. 549, JOB ADDRESS AND LOCA N... Owner's Name ---------- Phone "`'' ---------- Address_._._..�.---r�- __0-- ------------------------- --------- - ---------------------- ---- Contractor's Name---- -------- -------------------------------------------------------------- --------------------------------------------------------------- Phone - ----------- Installation will serve: Residence ,[Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other.❑ Number of living units: J____ Number of bedrooms 3--- Number o aths _'_1__ Lot size -------- _-_-_�_ ---_-----_-_______ Water Supply: Public system [_ Community system ❑ Private Depth to Water Table ________ ft. Character of soil to a depth of 3 feet: Sd Gravel E] Sandy Lo;PNo Clay Loam E] Clay E] Adobe 03'/Hardpan E] �}^ii► Previous Application Made: Yes E] No No New Construction: Yes ❑ ; TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public}} ewer is available within 200 feet.) Se Septic ank: Distance from nearest well___ ___i,!_--__Dista fr foundation___J_O________-Mate i -- ---- ______ _____ ff__-____. No. of compartments----------��---____-Size-- x -------Liquid dept ------------- ------------Capacity--- - --i-�0} 1 Dispos Field: Distance from nearest well_-__ _Distance from foundation__11 Z _�__Distance to nearest lot Iin��:v__-- Number of lines_______________s__ _ ____-__Length of each line------------ of trench---__-_- g ,� ------------- Type of filter mate rial_f��__.____ eepth of filter material________-L�-_-_-__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------------------------------------------------- from nearest building________________________________________- ❑ Distance to nearest lot line------ ------------------------------------------•--------------------------------------------------•----------------- -•-------------------- i Remodelingand/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, State laws, and rules and regulations of the San Joaquin Local Health District. (Signed)--' ------------------------------------------------------------------------------------------------(Owner and/or Contractor) By:-----------------------------------------------------------------------------------------------------------------------------------)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-5;-- ----- - -------------------------------------- ---------------------------------------- DATE__�----------------------------------------- REVIEWEDBY----------------------------- ------- - ----- -- -- --------------------- --------- -------------------------------- DATEr BUILDING PERMIT ISSUED------•---------- ------------------------------------------------------------------------------ DATE----------- Alterations and/or recommendations:_____-_ ------------------------------------------------- - }fid L ________ ________________ ------------------------------------------------------------------------------------------------------------------------------------ r fFy+ ---------------•------- -- ---------------------•--- ----------------- --------------------------------------------------------------------------------------- U ---- ---------------- --- FINAL INSPECTION BY---------------------------------------- ---------------------- Date-- . ----------------------------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT ' 130 South American Street 300 West Oak Street 132 Sycamore Street r` 814 North "C" Street Y Stockton, California Lodi, California Manteca, California `I" � Tracy, California ��JJ ES-9-2M 8-51 Revised W-2200