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APPLICATION FOR SANITATION PERMIT Permit No. 3_fz (Complete in Duplicate) l Data issued Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herain described. This application is made in compliance with County Ordina�nce� ,No. 549. JOB ADDRESS AND LOCA N.______•_,__[----I--- - - - ---------- Owner's Name--------------------- ------•------------------- ---- ---- . Phone_.._---- - ------ - ------------------ - •--- Address--------------------------------------------- -•------- a' V ---- - -- - - - - Contractor's Name = J�Y) •---------- ------- ---- --• - - -------- - --- Phone a Installation will serve: Residence Apartment House E] Commercial ❑ Trail//er Court E] Motel El Other E]Number of living units: _1.____ Number of bedrooms _o Number of baths ._.l--. Lot size _____________________________________ ---------------------- Water Supply: Public, system ElCommunity 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 publ' sewer is available within 200 feet.)r ' Septic Tank: Distance from nearest well_ _`C4Bfstance from foundation_..#-b___ Material__r-_-_. 'i�r No. of com artments`_ _Liquid depth__.___.___ p Size._ - Capacity---- . Disposal Field: Distance from nearest wel1_004Wl" Qistance from foundation___-__ „,. __.Distance to nearest lot line__ ---_____ Number of lines__________j_ of each line_____________ YI ------ -------- -Length ,:�--- ---.Width of trench-__._-- ' ,,�� n -- � ------ - Type or filter material_*.S,_!a-_11Gi "__Depth of filter material___-_ _ _1--------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__.._____.______. _ _ ❑ Sze:'Diameter' '” ----------------Depth----------------- `------- -----Liquid, Capacity n. -------------gals.= Privy: Distance from nearest well__.___------___________________________________Distance from nearest buildin - + 9 ------------------- ❑ Distance to nearest lot line----------------- = - ----------------------- ► r 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) .. /�-----------------------------------•------------- --- ---------------------------(Owner and/or Contractor By:------------------------------------------•----------•---------------•------------------ -----------------------------------------(Title)------------ ------i----------------------------------------- (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------- ----------- LEW ED BY-------------------------------- ------------ ------------------------------------------------------•----------- ---------- DATE------- BUILDING ERMIT ISSUED ------------------- -I--- ----------------- DATE----------------------- " -------- Aiterafians and/or recommendations:__.___._-- __•-____--- - - •----------------- ' " ------ - ----------------------•--- ---------------------- •-----------------••--•--------------•------------------ I --- -- ----------•-••-------^ ----------a..--------------------`------------ -- ----- ------------------------------------------- s 1 p -------—----------------- ---- ------------------------------------------—-------------------------------------------------------------------------------------------------- FINAL INSPECTION BY-------------------- .- -------- Date------------- �`. - -------------- ' 4 SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Straet 132 Sycamore Street 814 North "C" Sfreet Stockton, California Lodi, California Manteca, California Tracy, California ES-9-2M 10-52 Revised W-2100