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ie 'APPLICATION FOR SANITATION PERMIT Perr-4jt NA-3 `� - -------------- (Comple+e din Duplicate) Date Issue------ Application is hereby made to the San Joaquin Local Health Disltrict for a permit to construct and install the work herein described. This application is made in compliance with County 9rdinan eo. 549 f , JOB ADDRESS AND LOC TION._ -- - ----- --- ----- --- ------------=----------------------------------------------------------------------=-------- Owner's Name------------ _ -' Phone--- -------------------------------- ..i. -------------� ------_------------------------- -------___-- ----- - •- --------- •-- -- - -- -- - ----- ----- ------- Address ------- --------- ----------- __tom ,�► Contractor's dame =' ne Installation will serve: Residence Apartment House E] Commercial ❑ Trailer Court ❑ Motel L] Other E]Number of living units: __/__ Number of bedrooms�� II umber-of baths ._/__ Lot size ---- _ ___�__ __ ,�___ Water Supply: Public system [ Immunity system ❑ Private ❑ 'Depth to Water Table ________ ft. Character of soil to a depth of 3 feet: Sand ❑ Grave! ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe E10 Hardpan ❑ Previous Application Made: Yes ❑ No ❑ r New Constructiol: Yes t❑r No ❑ ri f TYPE OF INSTALLATION AND SPECIFICATIONS: � (No se tank or cesspool permittecl`it public sewer-is available within 200 feet.) pti T Distance from nearestell_ _Distanc} from fo ation__!___'-__-_.Material----- __---- - ----- - ------- ------------- Se No. of com artments__# -_-__Size___.Vl.�, �___Liquid de `th__ -__ -______Ca acit --d___ p 1 q ip Y Disposal Id: Distance from nearest e!E_ ._.Distance from foundation__, ( ___-__--Distance to nearest €otliinf__X____ Number of lines____p� - Length iof each line__ ___ - _1� ___.Width of trench-_-_ Type of filter materiaLA__- _ _,___ .Deptht�of filter material__ ___ �___'_.___Total length......... ------------------- t s+ t { -� �• k S Seepage Pit: Distance to nearest well---------- '___-_-Dista'rce from'foundation---- ---------------Distance to nearest lot line----------------- ❑ Number of pits------------- ------Lining material--�_=- - ------------Size: Diameter----------------------_Depth--------------------------------- Cesspool: Distance from nearest well------._�t------Distance from foundation-------------- Lining material---------___________________________- ❑ Size: Diameter-------------------------------------Depth- 1------------------------ -------------------:----Liquid Capacity----.-----------------------gals. Privy: Distance from nearest well_____________________________I------------------Distance from nearest building----------------_________________________- ❑ Distance to nearest lot line------------------------------I---------------- -- -- - -------------------------------------------------------------- -------------------- Remodeling and/or repairing (describe)--------- ----- -- -- ---I r -----•-------------------------------------------------------------------------------------------------------------------------------------------------:------------------------------------------------------------------- --------------------------------------------------•----------------------------•----- 1 - ------ --.----------------------------------------------------------------------------------------------- --------------------------------------- ----------------:-------------------- hereby certify that I have prepared this application and that the work will be doneiin accordance with San Joaquin County ordinances, State s, d rule and r gul tions of the Sa Joaquin Local/r,.,,,,n aDistrict.? R. i (Signed) - -- I- ' --------------(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). ` I � ' FOR DEPARTMENT USE ONLY a 46 APPLICATION ACCEPTED BY ------- --------------------- DATE------ s - REVIEWED BY------------------------------------- -----V -- - ----- ---------------------------------------- DATE---------------- ------------------------------------------ ' BUILDING PERMIT ISSUED-------------------'------------------------=--------------- -------------------------------------- DATE - Alterations and/or recommendations: ----------------------------------------- -------------------------------------- -------------------------••---------------------------------•-------- ----------------••--------------------------------------------------- ---- -----•------------------------ ------•-----•---------------•--------------------------------------------------------------------------------- -------------------------------------------------------------------------------------- ------------ ------------------------------------------------------------------------•------- --------------------------------------------------------------------------------------------------------------I----------------------•------------------------------------•--------------------------•--------------------•--- r , ( i FINAL INSPECTION BY:-------- ------------------------------------------ Date ------------------------------------------- SAN JOAQUIN LOC IAL HEALTH DISTRICT 130 South American Street 300 West Oak Street I 132 Sycamore Street 814 North "C" Street Stockton, California Lodi, California JI Manteca, California Tracy, California I ES-9-2M 8-51 Revised W-2100