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R - APPLICATION FOR SANITATION PERMIT Permit No. 3 :__RY___ __ (Complete in Duplicate) � Date Issued ___/z/-� 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 Orclmancp No. 549. JOB ADDRESS AND LOCATION___-__ _ _- Owner's Name---------------------- �0_---- -- -------------------------------------- ------------- hone------------------------ x I Address------------------------------------------ e •---------------------------------- 7 Contractor's Name Phone ---------------- Installation will serve: Residence//❑ Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ -Other ❑ Number of living units: __/--_ Nu 'i5er of bedrooms _-l___ Number of baths __I �' _Gl ' ---- Lot size -------- -------------------------- Water Supply: Public system Community system .❑ Private ❑ Depth to Water Table ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe Hardpan ❑ Previous Application Made: Yes ❑ No ❑ New Construction: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tank: Distance from nearest well________________ Distance from foundation-------------------Material___-__--________--_-____________________________ No. of compartments------------------------ Vize--------------------------------Liquid depth--------------------------Capacity----------------------- ' �. Disposal Fi ld. Distance from neares well ____.Distance from•foundatio __g_��____.Distance to nearest lot[� Number of lines_____ ------- - ____ Length of each line_______t24_________ ,Width of trench___ Type of filter materials_ _. t;�_Depth of filter material______/-_ _______Total length____________ __ _________.________ 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. �" _____Distance from nearest bdin ! . . :...Privy: Distance from nearest well- g --------------------------------------- ❑ Distance to nearest lot line------------------ - ---------------------------•------------------- i Remodeling and/or repairing (describe):______________ __ ___ _ _____f___________ _ ------------------------------------- ---- _ --------''' ---------- ----- -------- ----------------------------------------- -------------- ------- ---------------- -------------------------------------------------------------------- -------- ----- = = '"-----to------------------------ ------- ------------------- ----------------------------------------------------------------------------------------- I hereby certify that I have prepared this applica4ion and that the- o will be done in accordance with San Joaquin County ordinances, State laws, and rules and regulations oft a Sa�Joaqui oval Health District. . (Signed) f ------------- (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 EPARTMENT U E ONLY APPLICATION ACCEPTED BY r ------------- DATE-----�� ` i �----------------------- REVIEWEDBY---------------------------------- ----- --- ----------------------------------------------------------------- ------------- DATE--------------------------- BUILDING PERMIT ISSUED------------------------------------------------------------------------------------------------------ DATE------------------------------------- ----------------- Alterations and/or recommendations:-------------------------- -------- ----- -----------------------------------------------------------------------------•-------------------------------------- 4 ____________________________________________________________________________________________________________________________.________-___-_______--___________-.__________________________-_______ ________________________________________--______.._______________________________________________________________ _______________________________--____-___________________________________________-_____--------------------- f FINAL INSPECTION BY: -a-------- ----- -------�--------- --------`---------�-'------------------------------ 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 8-51 Revised W-2100