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` APPLICATION FOR SANITATION PERMIT Permit No. A..- 3.a lCom lete in Duplicate) � P Date issued ___-- -_-_[.p . ._.5'..3 P�pplication 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 Ordi ance N-o, 549" `'�f � JOB ADDRESS ANDf LOCATION-- -- -3-----1------ ----`------------------------------------------------ .. .............. Name---- i -- �L,� --------------------------- -- °% - -=--------------- •-------------------- Phone------------------------------•---- Contractor's Name-- --------- ------------ -------------------------------------------------------------------------------------- -------------------- Phone--------•------------------- -•---- Ins#allation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: ________ Number of bedrooms .------- Number of baths ______ Lot size ----------------------------------------------------________ Water Supply: Public system ❑ Community system 1] Private ❑ Depth to Water Table -------- ft. - Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe (] Hardpan ❑ Previous Application Made: Yes ❑ No ❑ New Construction: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 fee+.) 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_________________ 1l� ❑ Number of lines--------------------------------- Length of each line------------------------------Width of french----------------------------------- Type of filter material-------------------------Depth of filter material---------------------Total length___-_________________________________-___ W Seepage Pit: Distance to nearest well----------------------Distance from foundation--------------------Distance to nearest lot line_________________ \� ❑ Number of pits----------------------Lining material-----------------------Size: Diameter------------------------Depth--------------------------•------ v Cesspool: Distance from nearest well________________Distance from foundation-------------------.Lining material----------------------------.-__.__-- . ❑ Size: Diameter--------------------------------------D Pfh----------------------------------------------------Liquid Capacity gals. Privy: Distance from nearest well . __ .. _ ___ _.____.'__________Distance rom nearest building___ Ig-+ "__________. [V Distance to nearest lot line- Remodelin and/o. re airin , [describe):--- ----- __ ___ _______________ ____________ �• - Y ------------ ---------- •-'-�^^ 11------------- -- --------------- -------------- ------------- ----- ---------------------•------ ------------------------- ------------------------------------------------------------•--------------------------------------------------------------------------------------------------- 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)_ ------------------------------------------------------(Owner and/or Contractor) By:---------------........ ------ ---------------------------------------------------------- ------------------------------------(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_.r__' BUILDING PERMIT ISSUED------------- ------------------------------------------------- - ------ DATE - ------------------------------------------ Alterations and/or recommendafions------------------------------------------------------------------------------------------------------------------------------------------------------- ------ ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ -------------------------------------------------------------------------------- -----------/--------------------- ------------------------------- ----------- ---------------------------------------------------------------- FINAL INSPECTION BY-------------- f/ -&,y Z( Dale 2)1,r 3 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 $-51 Revised W-216D