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V f APPLICATION FOR SANITATION PERMIT Permit No. _________ 3 (Complete in Duplicate) 1 Date Issued 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 Ordinance No. 549. JOB ADDRESS AUZtOCATION---------------- ~------ ------------------------------------------ Owner's Name- __47,T�__ _ i --- --------- -----` Phone---------------- ` Address-----•------------------~..... 4k- ......_... Contractor's Name------------------ -------- - -------------------------------------------------------------------- ---- Phone----------------------------------- Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units. _��rn 6oms -_./--- Number of baths __/_ Lot size __-_-- -..� ------------- Water Supply: Public system ❑ Private ❑ Depth to Water Table ____:__ ft. 1 Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑' Clay-[-] Adobe dean_❑ t Previous Application Made: Yes o ❑ New Construction: Yes - Pd�-❑" �r t TYPE OF INSTALLATION AND SPECIFICATIONS: 1 (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Sepfiec Tank. Distance from nearest well-----------------Distance from foundation-_-_------_-------_.Material-__---.----_____._.._-----------___._____---_-__.t K Q No. of compartments—__--_--._ ze__'_-----------------------------Liquid de th.-.------___.._..__ ..---Capacity �y Disposal Field: Distance from nearst wellDistance from foundation_______ _ ._Distance to nearest lot line---L r Number of lines_____ ____._.___- Length of each line-70 r'_ Width of trench_____ -.- Type of filter material___,S _�_.�t-J Depth of filter material__ -- -----------Total length____--- _4 -_ ------------- Seepage _---___Seepage Pit:. Distance to nearest well_:.__.----------------Distance from foundation---__- ----------Distance to nearest lot line----------------- ❑ Number of pits-------------It-------:Lining material------------_----------Size: Diameter-----------------------Depth--------------------------------- Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material -__-__---_----__.----.____._ _- ❑ 4 x- Size: Diameter----------------- -------------------Depth-------------------------------------------------.--Liquid Capacity----------------------------ga . Privy: Distance from nearest well--- _- _ _---_-- • _'Distance from nearest building ❑ Distance to nearest lot line---------------------------------- ------------------ ------=-----------------------•------------------------------------------------------ Remodelin and r repairing {describe: ' --- - - ` -•-•- -- ------- --- ----- •---------- - ---------- - �- ; r i . ------------------------•--------------------- ------------- -------------------------------------------------------------------------------------- -------------------- -- ------ •---- ------=------------- ------1---------------------••---------------------------------------- I hereby certify that 1 have prepa d this apPI a{ on 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 Contractorl 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-----/ r REVIEWEDBY-------- -- ------------------------------------------------------------------•-------------------- DATE------------------------------------------------------ BUILDING PERMIT ISSUED--------------------------------------- ------------------------------------------------------------- DATE---------------------------------------------------------- -- Alterations and/or recommendations:----t----------------------------- ----------- ---------------------------------- --------------------------------------------------------------------------- ---------------------------------------------------•----•------------------------------------------•--------------------------------------------------------------- --------------------------------------------------------- -----------------------------------------------------------------------------=--------------------------------------------------------------------------------------------------------------------------------•-------------- 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-4-2M 10-52 Revised W-2100 f