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APPLICATION FOR SANITATION PERMIT Permit No. __3_3 3_- - (Complefe in Duplicate) � Dade Issue! ---/'I 1 4 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 LOC ION ---- _ -_ _ - -- ------ --------------- -- -------------- -- Phone Owner's Name +� Address---------------------+r -, ---------------------------------------•------------------------------------------------------------------- Contractor's Name---------------------------------- ----- Phone ----------------------------------------------------------------------- --- ---------------- Installation will serve: Residence Apar ent House ❑ Commercial ❑ Trailer Court ❑ Motel Other [] Number of living units:._ er of bedrooms 3-- Number of baths--_ Lot size -__ d-- -- -- ------------------ Wafer Supply: Public system Community system ❑ Private ❑ Depth to Water Table /Vift. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam Clay Adobe ardpan ❑ Previous Application Made: Yes Elsle No w Construction: Yes El No �❑ El f TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic ank or cesspool permitted if public sewer is available within 200 feet.), Septi 'Tank: , tante from nearest well-----------------Distance from foundation--------------------Material ______._____-__-_ o. of compartments ;;---------Site--------------------------------Liquid depth--------------------------Capacity Disposal F' R Distance from nearest we111 ��__Distance from foundation Distance to nearest lot line__4-____.__ umber of lines___- __---- Length of each line--------�_r� Width of trench___-----____- 01 Type of filter -------------------------- -----materiaiJ: r ._r oer material-. th f Cf ___�__ ••- •�. ______Total length_________________ Seepage Distance to nearest weifj---____ istance fF ound ion__ _ -._..____.Distance to nearest to line_ ---- Number of pits____ 1. p---_Lining material__ _ _ ize: Diarrieter--3--------------.Depth---_ oe 0 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)--------------------------------Y-------------- -- hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State I ws-, and rules a regulations of th San Joaquin Local ealth District. (Signed) / 0 -- --�- ---- � ------------- Own By:-------------- • = ntract and/or o or) - - ----------------------------------(Title)------ - - ----------- =------------- ------------------ ot plan, showing size of lot, location of system in relafion to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY-- DATE_! REVIEWED BY - ----- - ----- ---------- DATE----:7? -- ------------------------------------------------- -------------------------------- ---------------- 1N PERMIT ISSUED----------------- ----- - ---- -- - ------------- DATE----------�_ - - - - ---------------------------------------------- ---------------------------------- ----------- aerations and/or recommendations-----------_____-------------------------------- ---------------------------------------------------------------------------------------------•------------------- --------------------------------------------------- -------------------------------------------------------- ----------------------------------------------------------------------------------- FIN ------------------------------------------------ FINAL INSPECTION BY: _-_---------------- ----------------------- 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 1=S-9-2M 8-51 Revised W-2100