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APPLICATION FOR SANITATION PERMIT Permit No.4--`5 -- 3'd (Complete in Duplicate) y �- Date Issued 1 --___/_ 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 Ord* ante o. 549. JOB ADDRESS A O TION________ !- _.. + Owner's Name.______ ___ Phon -- --U_ Address ------------------- L Contractor's Name... ------------------------------ ------ • -- ---- ------- ----- --- Phone ----------------------------------- Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Mot9l ❑ Oth ❑ Number of living units_- V� umber of bedrooms .--_____ Number of baths ._-____- Lot size ___ __________________ __ _{ _______-_._______ ---- Water Supply: Public system Community system ❑ Private ❑ Depth to Water Table ft. A I w�I Character of soil to a depth of 3 feet: Sand E]Gravel ❑ Sandy Loam Clay Loam ❑ Clay ❑ Adobe Hardpan ❑ Previous Application Made: Yes E] No P/ New Construction: Yes No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if ublic ewer is available within 200 fe/eet��.y Septic/Tank: Distance from nearest wel stance from found Ion_t!_fl___________-Material__ .__- _________1_J___ [+ No. of compartments-------------- ------- --Size------�._0_ -Liquid depth__-- ----------- --------- --------- Dispo Field: Distance from nearest wel _- - _ Distance from f dation_��__--istance to nearest 1 t h IIt Number of lines --------- Length of each line ------ i_-41-p_____._.Width of trench._____ Type of filter materi ___ ----- �epth of filter material -------- 1_8 -_.__Total length _________�O- --- 00 Seepage Pit: Distance to nearest :y e_* ._j�Distanc�from.oundation__'"__:�_...___Distance to nearest lot l�i.n-ey_,;:__f______00 Number of pits______h�,!______--__ Lining material_ --Size. Diameter___ 4,__________-- Depth_._-__-_e�C,� '-_------__._ Cesspool: Distance from nearest well ----------------- Distance from foundation -------------------- Lining material _________________..________-.______ ❑ Size: Diameter---- - ------------------------------- De th-------------------------------------- -----------Liquid Capacity ------------- - --------- gals. Privy: Distance from nearest well ------------------------------------------------- Distance from nearest building .____.__-____._________-_---------------. V" ❑ Distance to nearest lot line - Remodeling and/or repairing (describe:---------------------- ----------------------------•-•-•-•------------------•-------------••---•------------------------------••-----U --------------•---•-----------------••-----•------•----------•----------...----------------------------------------------------------------------•---------------------------------------•---------------------------------- -----------------•--------------------•--------------------•--------------------•---•-----------------------------------------------------•----------------------------------------- .---------------------------------------- - ----------------------------------------------------------------------------------------•---------------- -------------------------•-------------------------------------------------------------------------------- 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;�rules d regu a ions of the San Joaquin Local Health District. (Signed) --)J rc/ ------------------ - -------------------------_---------------------------------------(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_----------------------------------------------------------- ------------------------- DATE - REVIEWED BY -------------------------------------------- ----------------------- DATE -- BUILDING PERMIT ISSUED------ ------• -------------------------------------------------------------------------------- DATE ---------- and/or recommendations: -------------------- ___________ ___ ------------------------------------------ --- f :-------------- x-----------------------------------------------•-•--•-•----------------------------•---------------------------------- ----------•-------------- --------- ---------------- ------------------•---------------------------------------------------------------------------------------------------------------•--------------------------------------------------------- ------------- -------------------•--•--------------------- --------------------------- _- ----------- ---------------------••----------------------------------------------------------------------------------------------------------- s FINAL INSPECTIONBY:_. � _�_-- ------------------ 7 � "- - .- -------------•----- Date -- ---- %%% 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 10-52 Revised W-2100