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APPLICATION FOR SANITATION PERMIT Permit No. _3 _. -- -- I ( - (Complete in Duplicate) Date Issued �- ' .. : Application is hereby made to the San'Joaquin Local Health District for a permit to construct and i stall th era describ This application is made in compliance withCountyOrdinance No, 549. JOB ADDRESS AND LOCATION___ _______ -- -- r^ H., ��— �' ------ ----------------- Owner's Name- _-• _--- ``-• A - hone--- ----- : Address----•-- -�.� •- - --• Phone --�� Contractor's Name----- -------------------------- =� �� - Installation will serve: Residence`❑ Els�Apartment House Commercial El ❑ Other Trailer Court ` E]1 Number of living units: __ _ I _.- Number of bedrooms _ Number of bats _ Lot size __ -: ---{ a------------------- # Water Supply: Public system`s Community system j] Private F1 Depth to Water Table��ft. �� Character of soil to a depth of 3 feet: Sand E] Gravel E] Sandy Loam ❑ Clay Loam [_1 Clay E] Adob Hardpan E] Previous Application Made: Yes El �' New Construction: Yes ❑ Na TYPE OF INSTALLATION AND SPECIFICATIONS: l t(No septic tank or cesspool permitted if public sewer is available within'200 feet.) Septic Tank: Distance from nearest well Distance from foundation--------------------Material----------------------------________----______- No. of compartments-------------- Size--------------------------------Liquid depth--------------------------Capacity..-------------------- � Disposal Field: Distance from nearest well_----__._-_____-Distance from foundation___________________Distance to nearest lot line________-______.. (, ` umber of lines----------------------------------Length of each line------------------------------Width of trench----------------------------------� ype of filter material----------------- ___ -Depth of filter material---------------/----_Total length----o2,�-( --30_`----•-,-1 Seepage Pit: Distance to nearest well Distance f om fo dation__/&-___ ____. Distance to nearest to ._ine___ ____ ____Cning material. Size: Diameter_____ ___.Depth____' a---------- ---- Number of pits____________ ��-- .. esspool: 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--------- - -------- ---------------------------------------------------------•- --------------------+------------------- Remoelin and or re airin describe ________________ __ -----.a- --------------------------------------`------------------- p g .. ,»f g R r _._.r _ ...,.. - .k . -1 ________________________________________________________________________ --------- -------- .,,.cz. ------------- -------- 1 �- ------------ ----------------------------- �-� '°° `' � v ------------ - ------ -------- ------------------- --------------------•----------------------------------------------------------------------------------------------------------------------------------------- f' 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 s and regulations of the San Joaquin Local Health District. (Signed) __{Owner and�or C tractor) g )----.- -- - --- ------ ------ - -- -- --- - - - -- - ----------------------------------------------------------- ---�.. -------------------------------------------------------------------(Tit } (Plot plan, showing siz .of lot, location of system in relation to wells, buildings, etc., can be place on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY------- __________- DATE_______________ f - - ----------------------- DATE-------------------------- ---------------- - REVIAWED BY------------- ----------------------------- ---------- - ------------ ----------- --- - r BUILDING PERMIT ISSUED DATE------------------------------------------------------------- ----------------------------------------- Alteratinns and/or recommendations:___________.__-__._-..----.___.-- ---------------------------------------------------- --------------------------------------------------------------------------------------------------------------------- --------------------------------------------------------------- -------------------------------------------- - - -- ----------------------------------------------------- FINALINSPECTION BY--------------=- -- ---- --------------------------- Date..... -/-----J-7-!- ,5Z------------------------------------------ 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-9-2M'8-51 Revised W-2100