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APPLICATION FOR SANITATION PERMIT Permit No.,,3.--y-r--____._ (Complete in Duplicate) 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 AND LOCATION------ .1- '� Owner's Name--------- ----------- - ----- ------ -- - ------- ... - ------------ ---------------------- Phone--------------------------------•--- Address------------_--•------------- ---_---------- .4•-- --- --- --...-------------------------------------------•------------------------ Contractor's Name--------_------ -- ---------- ------- --- ------ ------ ----------------- --------------- Phone--------------------•-------------- y Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ ' Number of living units: ________ Number of bedrooms -------- Numb;,�; afer r f baths :_ Lot size ------------------------------------------------------------ f Water Supply: Public system 0 Community system El Private Table -------- ft. Character of soil to a depth of 3 feet: Sand-[] Gr sl-0 -Sandy Loam ElClay Loam _ Clay ❑ Adobe ardpan ❑ ` Previous Application Made: Yes ❑ No ew Construction: Yes 1 TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Se tic Tan cL: Distance from nearest well_______________Distance from foundation__________________. 11 No. of compartments-------------- - ------Size--------------------------------Liquid depth--------------------------Capacity = Disposal Field: Distance from nearest well__. istance-from founds ion_______ Distance to nearest lot line1,�_.__: ._rt Number of lines------------------------ Length of each line-- - "` Width of trench------ -----------_ - -•-- ' T e of filter materia�e__ __, Depth of filter material--_ __ Total length_____, ------ . :__.__ Seepage Pit: Distance to nearest well______________________Distance from foundation-------------._____.Distance to nearest lot Ii ___________-____ ❑ Number of pits------{------------_Lining material-----------------------Sze: Diameter----------------- Depth-------------------------------- El Distance from nearest well-----------------Distance from foundation--------------------Lining material_____-_.--____-.-_------.---.-__.__ Size Diameter---------------------------------------De th ❑ .-..�. ---P --------- ----------- -------- ----- _Liquid Capacity�.�-----------------�,9a s. i Privy: Distance from nearest well ____..____ Distance from nearest building------------------------------------ ❑ Distance to nearest lot line--------------------------------------- ------------------------- -------------------------------------------------------- ------ ------ Remodeling and/or repairing {describe)______________ L ------- ---------- - ------ -- --- --- -- - --------------------------------- -- .6.,- ---- � - - -- r. --------------------- ----------------------------------------------------------------------------------------------------t------�11____ -------------------------------------------- --------------- ---------------------------------------------------------------• ------------------------------------------------------------------------.--------------------------------------------------------------- I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State ws, and rules and regulations of the San Joaquin Local Health District. a (Signed)_ ---------------------------------------------------------------------------(Owner and/or Contractor] By:------••-•------------------------------------ -------------------------------------.---------------------(Title)---------------------------------------------------------------- (Plot pian, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY 1 APPLICATION ACCEPTED BY-----------= ------=-- ----- ----------,----------------------------------------------- DATE---------.�r '�''` -�---------- REVIEWED BY-------------------------------- - 1 ------ DATE----------------------------------------------------f------ ---------------------------------- ---- --------------------- BUILDINGPERMIT ISSUED----_-----------'------------------------------------------------- DATE �--------------- ..- Alterations and/or recommendations: --•. -- l�d' s� � °� �.-... -- -•------------------------• c.� �.- �-- /.5�*, -----------------------------• --------------------,. . ----._.....-------------•-------........... -------------------------------------- ---------------------------------------------I---------------------------------------------------------------------------------------------------------------- - ----------- --------------------------------- •--------------------..-.------------------------------------------------- ------------------- -------- --- FINAL INSPECTION BY:_____...__`.____- -- ----- --------------------------- Date.-.------- --- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Street 814 Nor+h "C" Street Stockton, California Lodi, California Manteca, California Tracy, California ES-9--2M 10-52 Revised W-2100