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APPLICATION FOR SANITATION PERMIT Permit No. _ _3--- --__-_ �' (Complete in Duplicate) Date Issued ._3_-------`-------. V 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 O dinance o. 549. JOB ADDRESS ND LOCATION-� ---tj------ . --/�---------------------------- --------------------•-----------------•---------------.--------- ' C n ]( Owner's Name # ----- ------------------------------------ Phone -- f,/1 . Address--•---•--------•--•----.----- -••-------------------------------------------------------------------- Contractor's Name-- ---•- -------•-- •-------- ---------------------------------------------------------------------------------------------- Phone----------------------------- - Installation will serve: Residence [Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ i Number of living units: --_V_ Number of bedrooms--_L Number of baths 4___ Lot size -__ ---I----__KJ_A -__'__________________ Water Supply: Public system VCommunity system ❑ Private ❑ Depth to Water Table ft. Character of soil to a depth of 3 feet: Sd Gravel [-] Sandy Loam Clay Loam L __-lay ❑ Adobe E] Hardpan E]E] an Previous Application Made: Yes No New Construction: Yes Mr No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if publip sewer is available within 200 feet. j Septic ank: Distance from nearest well_ss� `�_-Distan 1 fro �oe�n c ion--- --------------Mater•�I-_---------_--- -- -_.- _---_________ ---------- 27X _---- y No. of compartments_______________ __*--__-Size_.-X_ _ __ __Liquid depth___-_ 7_________.___Capacity__�� Disposal Field: Distance from nearest well-<=5'04 ODistance from foundation___2.'_------Distance to nearest lot ine % , Number of lines____________ __ Length of each line._--___-_-_----_____ �V.Width of trench___--_--__ f_________^M -- y r� 1 *.i Type of filter material --_..__'Af"�-Depth of filter material----___�-{�--.--_Total length_____________________f. -_------__ Seepage Pit: Distance to nearest well-----__--------------Distance from foundation------------------..Distance to nearest lot line-----------------E ❑ Number of pits----------------------Lining material-----------------------Size: Diameter---------------------- Depth--------------------------------- Cesspool: Distance from nearest well-------------_-_Distance from foundation-------------------.Lining material---------------------_--___-____--_. ❑ Size: Diameter------------------------------- ------Depth----------------------------------------------------Liquid Capacity----------------------------gals. Privy:' Distance from nearest well------------------------------------------------Distance from nearest building ❑ Distance to nearest lot line---------------------------------------------------------------------------------------------------------------------------------------------- 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 Coun ordinances, State laws, and rules and regulations of th San Joaquin Local Health District. (Signed)--- - ---- - ------%------------------------------ ------------(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 . r APPLICATION ACCEPTED BY -- - -------------------------------------------------------------------------------------- DATE- -- ---------------- v REVIEWEDBY----------------------------- ---- --- ------------------------------------------------------------------------- DATE .moi BUILDING PERMIT ISSUED------------------ DATE ✓'� `� .� M. ---- Alterations and or re mmendations:____--__.--�-- --- -�--- ---�__--- ------------ -- �_- � �' ___�_______r_.. __'___�_f___.______ --_ .-_.___-__-___-__-___-____ __._--..____.__ -...___________•__----..__--_-- ____-_ r'A�_'3. !'`!F".'L�'!_.__ ___________ ----------------------------------------.__.----___-----____--_-____-_-- ---------------------------------------------------------------------------------------------------------------- --------------------------------------------- -----`-___-_.---- ._.___ -- _____ ____------------- --------------- ----------------------------------------- -------------------------------------------------- FINAL -------------------------_--------------_.---FINAL INSPECTION BY------------------ -- ------------------------------------------ Date------------ --�----- 1 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 it ES-9-2M 8-51 Revised W-2100 I