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APPLICATION FOR SANITATION PERMIT Permit No. 3-_ __.. 116 - (Complete in Duplicate) Date Issued.?_-- I Applica{ion 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 Ordinannce�No. 549. JOB ADDRESS AND LO TION-------5.7_- (--- -- -------' "' �!..-.---- -------------------- , --------------------------------------------------------------------- aUwk if�10 Owner s Name -- -- --- ---- ----- '•--------------------- ------------------ Phone-- •------•----•----------•--- Address-----------------�'"�-�--"--- - ----- ----•------------------------------"----� ------------ ----•--------------------------------------------------•--------------______-___-------- Contractor's Name---------------- •----:-.-----'------------------------'-------------- ---------------------- ----------------- Phone----------------------------------- Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court p Motel ❑ Other ❑ Number of living units:_-#--- Number of bedrooms :2-d- Number of baths I___ Lot size __ ---7---�_z'_*�'__A7770------------ Water Supply: Public system Community system ❑ Private ❑ Depth to Water Table -------- ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy L°am ❑ Clay Loam ❑ Clay ❑ Adobe 0-'*`Hardpan ❑ Previous Application Made: Yes ❑ No [g'�`New Construction: Yes ❑ No 2_' TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) a � r Septic Tank: Distance from nearest well_ _Distance from.foundation_I'D____-_-___.Ma arial ___ _-___ -------------- p �j?4.X-Y x/�__Liquid depth_- ----- Capacity-- -- ------- No_ of com artments_.-__I�,- ------_ Size___ Di poral Field: Distance from nearest well ++_,Distance from foundation_-Lp_--__----.Distance to nearest lot line__ I Number of lines-_-------I------------- ---------Length of each line_____/---2-_*-------------Width of trench--_-fr__'lt---------------------- Type of filter material---e%f'C -------Depth of filter materia!___._,-__-.-______.Total length---- -- ------------------- km 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-------------------------------_____. ❑ Size: Diameter------------------ ------ Depth- --------------- ---------- ---- -—)L---- ------Liquid Capacity----------------------------gals. rn Privy: Distance From nearest well____ -------------------------Distance from nearest building---------------------------------------_ ' ❑ Distance to nearest lot line ------------------------- ------------------------------------------------------------------------------------------------------------------ Remodelingand/or repairing (describe):------- -------------------------------------------------------------------••----------------------------------•------------••---------------------•---- v� -------------------------------------- -------------------------------------------------------------------------------------------------------------•---------------------------------------------------------------------- -- ' ------------------------------------------------------------------------------•------------------------------------------------------------------------------------------------------------------------------•---- ------ 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 .ules and regul tion sof the San Joaquin Local Health District. 3 (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 APPLICATION ACCEPTED BY------------------- ------------------------------------ ---------------------------------------- DATE------ ---------•----- •--- REVIEWED BY-------------------------- ------- BUILDING PERMIT ISSUED---------------------- ---------------------------------------------------------------------------------------- ----------------- DATE Alterations and/or recommendations:-- ---------------------------------------------------------- ------ ----------------------------------------------------------------------------------------- ------------------------------------------------------------•-------------------------------- --•--- ----------------------------------------------------------------•---------------- _----••-------------------•------ -------------------------------------------------------•----------------------------------------------•------------------------------------------------------------------------------------------------------------------•--- ---------------- FINAL INSPECTION BY---- ---------tl-- ------------ -- ------- Date----------�� 3 ----� ... 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 Revised W-2100 - _f