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� APPLICATION 1=0R SANITATION PERMIT Permit No. 3 jj (Complete in Duplicate) Date Issued V/ ~' l 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 Ordinance 549. JOB ADDRESS AN AT N. - --- j ---------------- --/ Owner's Nam ------ r-------• - --- Phone_- ' Address -- ..... ---•-- ---------- -- -- -------------- ------ ---------------------------------•-•---------------- ---------------------------------------- Contractor's Name --- --- ---------------------------------------------------- Phone j -- Installation will serve: Residence Apartment Ho Commercial ❑ Trailer Court 0 Motel ❑ Other ❑ I Number of living units: _ __ Number of bedrooms -4 Number of baths __/__ Lot size -------------------- Water Supply: Public system Community system ❑ Private ❑ Depth to Water Tabled ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Ado�Hardpan ❑ Previous Application Made: Yes ❑ No New Construction: Ye No ❑ TYPE OF INSTALLATION AND SPE ICA IONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) P aO_ Distance from nearest well_________________Distance from foundation-------------------Material------------------------------------------------- No. of compartments--------------------------Size-------------------;-----------Liquid depth--------------------------Capacity---------------- `W Distance from nearest well-________________Distance from foundation_____________.____Distance to nearest lot line------------------ Number _____ _._-._.__. �\ Number of lines-----------------------------------Length of each line------------------------------Width of trench----------------------------------- / Type of filter material------------------_______Depth of filter material _--------------_____Total length----------------------------------------..__ Seepa a Pit: Distance to nearest welfl�____Distance f ,fou ationl`.1__....___.Distance to nearest lot line_____ Number of pits___/----------------Lining material Size: iameter_ 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 Irnel4ev ----- --------------- Remodel' an /or r-e iring (describe):-- r --- ---•-- ------- --------- ------- ........ ------------r- ----------------------- -------------------------- ---•---••-------------------- ---.------ ----- -- - ---------- ------------------------------------------------------------- -----------.---------------------------------------- ---- -----------------------------------------------------•-----------------•--------------------•------------•-------------------------------------------------•------------------- ------------------------ 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 rul regulatio o he San Joaquin Local Health District. - - ------ - Own or Contractor (Signed)------------- ---- -- ( l By__________________________________________ ______ __r___ _ ____.._________-__-______--.___________________________--_______(T1tl _ _-.______._ (Plot plan, showing size of lot, ation of system in relation to wells, buildings, etc., can b aced on reverse e. FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY---------------------------czpao -------------------------------------------- DATE----- `, REVIEWEDBY- •------------------------------------------ ----- ---------------- ------------------------------------------------------ DATE------------------------------- BUILDINGPERMIT ISSUED----------------------------------------------------------------------- ------ DATE------------------------------------------------------------- Alterationsand/or recommendations:-•---------------•-------------------------•-- ------------•--••---------------------------------••-----•••---------------------•-------------------•-••------- -----------•-------------•---•-------------------------------•-------•------------------------------------------------------------------------------------------------------------------------------------------------- -------------------------------------------•---• ---------------------•----------------------------------------------.....---•----------------------•--------------------- -••--------------------------------•-----------•--- --------------------------------------------- ----------------------------------------------------------------------------------------- ---------------•------ ---------------------------------------------------------- --------------------------------------------- --------------------------------- --------- ---------------------------------------------------------------------------- ------------------------------------------------------ FINAL INSPECTION BY: hT' i<�`'__--------------- Date---------2-- -- // --------------------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Street 814 North "C" Street S+ockton, California Lodi, California Manteca, California Tracy. California E5-9--2M Revised W-2100