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APP IhCATION FOR SANITATION PERMIT Permit No.3------ ___(C(Co mplefe omplete in Duplicate) p d Date Issue I Ap lication is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described. i This application is made in compliance with 'County Ordinance No. 549.• + a JOB ADDRESS AND CATIO ______._--.__e __ _ -------------------- 0111 Owner's Name - ----- ------ Phone. -� .•._ Address----------- - --- ----- --------�U t'. Coritractor's Name---_--------------- one t Installation will serve: Residence Apar+ ent ouse ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: _ __ Number of bedrooms g ,-- � Number of baths _ .• Lot size ------- Water Supply: Public systemrtk_�Communiiipty system El Private E] Depth to Water Table hft. r; Character of soil to a depth of 3 feet: Sana ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑' Clay ❑ AdoHardpan ❑ k Previous Application Made: Yes ❑ No �' New Construction: Yes ❑ No, - TYPE OF INSTALLATION AND SPECIFICATIONS: ` r (No septic tank or cesspool permitted if public sewer is available within 200 feet.) 7� /'Septic Tank:_ Distance from nearest will _____-_ _Distance from foundation-------•------------Materia---------------- --------- .. ....... . ....__ __.kA I "- � /rr No. of compartments-----� ---- - - Size- ---------- ---Liquid depth---- = Capacity---------------------- Disposal Fiie`I ,, 'Distance from nearest wlell------- Distance from foundation--------------------Distance to nearest lot line_-.--______._-___ </�,'��,/f Number of lines-------------- -------------------Length of each line------------------- ----------Width of trench.---------------------------------- I 1� Type of filter material---- ------------ _Depth of filter material-----------------------Total length-_.______ ____________ ________.__�_.. Seepage Pit: Distance to-nearest well —Distance f ouation _____ _-_Distance to nearest lot line_ _____.' 1 Number of pits------- _ _ _ iring materialSize. Diameter_.____ Depth______ -_. ------------- Cesspool: ----- ----Cesspool: Distance from nearest w ll _Distance from foundation------. -------Liningmaterial �--- ❑: , _. material-- - _ . r — Size; Dismetec__. - � De th_ _- Liquid ,Capacity_. _ - 0-1 ---- -- gals.- - ._- - - .- i Privy: Distance from nearest w well _ ____------_ _ ________________ ____ _Distance from nearest building------------------.-___:-_---._______:-. I ❑ Distance to nearest lot liyne- - ------------------------------------------------ ---------- 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 County ordinances; State laws, and rul regulaiiori the San Joaquin Local Health District. (Signed)--------------- --- � --- - ------- --- - --- •^ - (Owner an Contractor) BY: -;------. ---------------------------------------------------------------(Title) -"'�---- - - (Plot.plan, showing size of lot, location of sys:em in relation to wells, buildings, etc., can be pl ed on reverse ide). 1� $ FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY_:_ . ._ ___ DATE ---------- E ` ------- REVIEWED BY '•- wN --- 3 DATE ----------- BUILDING PERMIT ISSUED - --- ---- ----- ------- -- ---------------- DATE---------- Alterations ----Alterations and/or recommendations:.-----....... ---------------.-------- --______.-------------------------------------------------------------------------------------------- ----------------------------------------------------------------- -----•----------- -----------------------------------------------___ ------_.------------------------------------------------------ I f ------------- -------------------------------------------- yN------------------- ------------ ----------------------------- ------------------------------------------------------- --------- ----------------- --------------- ----- --- --- - --- ----- - -- - - --- --- ---- - -------- --- r FINAL INSPECTION -BY---------------- - ---` ;--- ,_-- -__-- Date=------- --- -=g I SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Street 814 North "C" Street # �f Stockton, California Lodi, California Manteca, California Tracy, California ES-9-2M 10-52 Revised W-2100 /