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el - APPLICATION FOR SANITATION PERMIT Permit No. 3 _ _ �Itl ��i (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 i Th Fs application is made in compliance with County Ordinance No. 549. descr bed. JOB ADDRESS AND CATI N-____- -------- •-----------------------•------------------•----------------------©------------- Owner's Name---------- ---- ------' ----------------- Phone.--c-1 ( f� Address ---- -- -------------------------------------------------------- ------- ----/--------•-- Contractor's Name-------------- --------- ------ - --------- •-------- Phone---1---q-d--C/ Installation will serve: Residence Apartment House E] Commercial E] Trailer Court ❑ /Motel y❑ Other ❑ Number of living units: --- __ Number of bedrooms ._�Z Number of baths ---L Lot size - ----------------------------------- Water Supply: Public system Community system ❑ Private ❑ Depth to Water Table Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe 0--*'Hardpan ❑� Previous Application Made: Yes E) No New Construction: Yes [7 No DR,` TYPE OF INSTALLATION AND SPECIFICATIONS: i O (No septic tank or cesspool permitted if public sewer is available within 200 feet.) p Septic Tank: Distance from nearest well ___________-----Distance from foundation-------------------Material___________._..______ ❑ No. of compartments--------------------------Size---------------•----------------Liquid depth.-------------------------Capacity---------------------- Disposal field: Distance from nearest well------ ------Distance from foundation_____/-Q__. _.__.Distance to nearest lot l ine__Mt`�Q_. Number of lines____ __________ --- ___Length of each line--------/d---- Width of trenchf-,7.2 Type of filter material__�-�a---- ___Depth of filter material_____--/ __i�---------Total length--------/d-_-- Seepag Pit: Distance to nearest well-___�--.--_-_Distance f�)m fou dation------��____..Distance to nearest lot line Number of pits Lining material '�"--- -------Size: Diameter .�� ----Depth-----v4------------------------ Cesspool: Distance from nearest well---.___-____.__Distance from foundation--------------------Lining material------._- ---------------------------- El Size: Diameter Depth Liquid Capacity ga 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, State laws, and rules and regulations of the San Joaquin Local Health District. (Signed)-------------------------- -- --�__ __ ---------------(C*nw and/or Contractor) ------------------------------ By:----------------------- Y Ti+le--- [ ) --- - ------------------ (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 REVIEWED ---------------------------------- - -------------------------------------------------------------------------------- DATE --�--- BUILDING PERMIT ISSUED ------- --=----------------------------------- -----------------•-------------------• DATE---------- ? ------------------------ terations and/or recommendations--------------------------- ----------------------------------------- ._.___------_---_ -------------------------------------•------------------------------------------ --------------- -------------------------------------------------- FINAL INSPECTION BY:_.- -------------------- ------------ Date Y/ .� SAN JOAQUIN LOCAL HEALTH DISTRICT 130•Soufh• American Street 30D 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