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- 3 APPLICATION FOR SANITATION PERMIT Permit No. --------- (Complete in Duplicate) Date Issued ��r'/s 3 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 rdinance No. 549. // qq JOBADDRESS AND L CATION...JJ_ ? - --- •------------------------------------------- -----------------•------------------------------------------------- Owner's Name----------•--- --------- -------- --------- --------- ----------------------------------------- -- Phone_&__ 334_ -------- Address------------- -------Address-----•---------Z-F ----------------------------------------------------------------------------------------------....---•-------------------------------- ` ."p_�Contractor's Name---------- ---- ----e ------ -----•------------------------ --------------------------------------------- Phone_ . Installation will serve: Residence ❑ Apartment House ❑ Commercial ❑ Trailer Court ❑ Mot/ell❑ Other [► .p ' Number of living units: _ig--- Number of bedrooms __ _._ Number of baths ___I.-. Lot size - � ✓ �_________________________ Water Supply: Public system 21-1community system ❑ Private ❑ Depth to Water Table ft. Character of soil to a depth of 3 feet: . Sand Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe 2r/Hardpan ❑ Previous Application Made: Yes ❑ No New Construction: Yes 0 No [ TYPE OF INSTALLATION AND SPECIFICATIONS: �', - ►�., (No septic tank or cesspool permitted if public sewer is available within 200 feet.] Septic Tank: Distance from nearest well----- -Distan e� from foundation___ --------Material-_�___L------------------ --- ___._�________ �+_________._ No. of compartments------- _____________Si-b _f` z:_ _ ---Liquid depth--._ e�....------..CapautY-- Q------. - - Disposal Field: Distance from nearest wed-___-_'- �._.Distance from foundation q---��_.___._.Distance to nearest lot line____l�o._______-®tel Number of lines_____________ _/-�+_ .____--__Length of each line______cx�.Q .` __._.Width of trench----s _ __ }} --------------------- Type of filter material!-:a-__ ___Depth of filter mate nal_-__._-�_ -----------Total length--- . - - ` �Q See a Pit: Distance to nearest well ._.__"'_+____Distance f o� foundation__. ___-_.Distance to nearest lot line_________ Number of pits--------- p______-----Lining material -"- --Size: Diameter---- _r�-_._._.Depth___ct �________________ k , 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 line--------------------- ------------------------ ------------•--------------------------------------------------------------------------------- h9 T Remodelingand/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 rules and regulations of the San Joaquin Local Health District. (Signed) - : and/or Contractor) {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--------- •-�------ � -------------- REVIEWEDBY----------------------------------- ---------------------------------------------------------------------------------------- DATE------------------------------------------------------------ BUILDINGPERMIT ISSUED------------------------------------------------------------- ---------------------------------- DATE------------------------------------------------------------- Alterationsand/or recommendations:------------------------------- ------------- ----------------- ---------------------------------..----------------------------------------------------------- --------------------------------------------------------------------------------------------------- --- ----------------------------------------------------------------------------------------------------------------------- - ---------------------------------------------------------------------------------------------------------•-------------- •---------•- ••-•--•---- ----------------------------------------------------------------------- --- - - --,----------------------- --------------------------------------------------------------------- FINAL INSPECTION BY: ----- �Datl*..-------------b lP �" SAN JOAQUIN LOCAL HEALTH DISTRICT 1 130 South American Street 300 West Oak Street 132 Sycamore Street 814 North "C" Street t Stockton, California Lodi, California Manteca, California 44 Tracy, California t &ES-9-2M 10-52 Revised W-2100