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APPLICATION FOR SANITATION PERMIT Permit No. 3 SCS (Complete in Duplicate) Date GIssued 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 C unty Ordinance No. 5549. JOB ADDRESS AND LO TION___ __ _ __ ____ ______ wner's Name______ __-_ P -- Addressf - ---- ---- Contractor's Namef----•- --------------------- ------ Phone----------- Installation will serve: Residence Apartment House El Commercial ❑ Trailer Court ❑ Motel Other ❑ Number of living units: ---� umber of bedrooms —2—-- � Number of baths .-.-__ Lot size _414Z..'-op _,� - .y�-------------------------- Water Supply: Public system ❑ Community system p Private Depth to Water TableW-- ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loom Clay Loam ❑ Clay ❑ Adol ardpan ❑ Previous Application Made: Yes ❑ No New Construction: Yes No TYPE OF INSTALLATION AND SPECIFIC TIONS: �� 1,., (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--------------------------Size--------------------------------Liquid depth---------- ---------------Capacity---:------------------- Disposa Fiefd: Distance from nearest well-- --Distance from foundation__ _�ODistance to nearest lot li e___ --------- Number of lines_______,_ __ ---- ------ __ Length of each line______ _ _ _______.Width of trench.._.__.-- --- /�� - �� J --------- ------------- Type of filter materia _ __ _____ _______Depth of filter material------/_';"**If_____. ------------------ length------ -__---__.__-_-_-_ Seepage Pit: Distance to nearest well----------------------Distance from foundation--------------------Distance to nearest lot line----------------- ElNumber of pits------------ ------Lining material----------------------Size: Diameter-----------------_---Depth--------------------------------- Cesspool: Distance from nearest well--------------___Distance from foundation--------------------Lining material------------------- - El ---------------- -------------- Size:.Diameter : : -. Depth..- -- y- _ Liquid Capacify----•-------•---•-- -gals. _ —� -- 9 Privy: Distance from nearest well-_____________________________ ________________Distance from nearest building-------------.------------__ ❑ Distance to nearest lot line_______ ___ Remodeling and/or repairing (describe):---------- 01 ------------ --------- ----- ------------------------------------------------------••-----•------------------------------•------------------------••------------------------------------ ------------------ ..................-------------- I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, Stat ws, and s pfd regulati6ns of the San Joaquin Local Health District. (Signed).......... ---- --- r --;�------ -- ------------------------------------------------------------------------------------- - -(Owner and r Contractor) ----- By: Ems. - - ------------------------------------------------------------- (T + itleJf (Plot plan, showing f lot, lova n of system in relation to wells, buildings, etc., can beed on reverse side , FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY-------------------------- -----------------t} e E - ------------------------------------ DATE---------- REVIEWED BY DATE •� - - ` ---------------- BUILDING PERMIT ISSUED -----------------------------------------------------------•-•-----------------------• - DATE---------------------- ° Aterations and/or recommendations:------------------------------------------ --------------------------------- ____ ._ ------------------------------------------------------------------------------------ ----------------------------------------•-------------•---------. ----------------- FINAL INSPECTION BY___ _____ ________ � 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