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'3 APPLICATION FOR SANITATION PERMIT Permit No. .. 3 -(Complete in Duplicate) f . Date Issued 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 AND LOCATION ----- - --- ' Phone---------------------- Owner's Name---- -----•------------------- ----- -------------- Address----------Lr r ---------------------•------------------ Contractor's Name---- ------ = ------- -- ---- ---------------------- - ----- ------ Phone----------------------------------- Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court El El Other ❑ of bedrooms _ __._ Number of baths V Lot size _ Number of living units: ---/---- Number, IIS Water Supply: Public system K Community system El Private ❑ Depth to Water Table' "____ ft.—' Character of soil to a deptof3 feet: Sand ❑ Gravel'❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe 1< Hardpan ❑ Previous ApplicationMade:!Yes E3No� New Construction: Yes IN_o El TYPE OF INSTALLATION AND SPECIFICATIONS: , (No septic tank or cesspool permitted if public sewer is available within 200 feet.) ptic agk: Distance from nearest well-----------------Distance from foundation--------------------Material____---_____.__-_______---._______-._.-____-_-. No. of compartments-- --------------- --Size--- Liquid deprth Capacity----------------------- ll, �� I( Disposal Field: Distance from nearest well�_�-:,Distance from foundation__-__-]--�__._.-_.Disfiance to nearest lot k�e:___ 11 1Length of each line_____- Width of trench._-�.- ______________________ Number, of lines------- -- ------------L -- g Type or filter materi -------- .- _ epth of filter material____._I_�__.._ -----Total length------ A-- -------------------=--•- Seepage Pit: DistanA lo nearest well-----------------------Distance from foundation-------------------.Distance to nearest lot line----_______-_____ Number of pits----------------- ----Lining material--------•-------------.Size: Diameter-- Depth Cesspool: Distance from nearest well_-__________..t-Distance from foundation;-------------- Lining material-_____________________________--___. ❑ = 1 r Liquid CaPacitY- -----------------------;- gals. Size: Diameter----------------------------- - De thi ,I. , i Privy: Distance from nearest well--------=------------------------------------- --Distance from nearesr building----------------- ----------------------- ❑ IE -- - ----- ----------------------------------------------------- •----- Qistance to nearest lot line-.-----:'--------- -- . ------ Re deling and/ r ra risig (describe - �' "" ------ - -------- ----------- ------- T.. .. l # -•------- ----------------------------------- > ---------- --------------------- -- l� ---------------------------------- I hereby certify that Ihave 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. s ' ' R 1 (Owner and/orContractor) (Signed) l ------- - Title --- -- ---------- -- ----------=----------------------------------------- (Plot plan, showing size of ';lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). j� FOR DEPARTMENT USE ONLY q. DAT>w------ APPLICATIONACCEPTED BY------------------------------- -- ---- --------------- ---------- >/----- ------------------------------------------ REVIEWED BY------------------4M=------------------------ ----- DATE �D------ ------------------------- __ DATE--------- --------2• - - 7 BUILDING PERMIT IS + { Alterations and/or recommendations--------------------------- V------- --------------------- ----------------------------------------- _ . I _ I� . �� _..---_--..-------------------------------------- ---------• FINAL INSPECTION BY: ! Y S == Date----- `� C------------------------------ 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 E5-9-21v1 Revised WI-2100