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APPLICATION FOR SANITATION PERMI Permit No. � 3-�_ (Complete in Duplicate) Date Issued ---- This � Application ' h?re6vyade to the San Joaquin Local Health District for a permit to const" rund install th wo k This application is made �ION mpa4�4)_'L ounty Ordinanc No. 549. hwrei escnbed. MAA- trlwy JOB ADDRESS AN O - - "Owner's Name.------- :: . 1 f ---- ------ --- ---- Phone Address------------------------ ---------------- ---- - yy Contractor's Name_-- ___--'-----•_-' --------------- Phone_-7j:!-7j:! -------------- •-------••----------•---- --•-------•----- Installation will serve: Residence E] A rtment House ❑ Commercial ❑ Tr, .er urt ❑ Motel p Other Number of living units: -------- Number of bedrooms ________ Number f Je#rs _ of size _ '______________------------------------------------ Wafer __ ____ i _�p� --------------------------- Water Supply: Public system ❑ Community system ❑ Private depth to Wage�abl ftp Character of soil to a depth of 3 feet: Sand Gravel ❑ Sandy Loam Clay Loam ❑ Clay [-] Adobe E] Hardpan ❑ Previous Application Made: Yes [] No ENew Construction: Yes 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 wel _--_ Distance from fo ation_`_f1 �a� Iula�real ------------------- ❑ No. of compartments---------- ,,II_ Siz�J_.x' x -----Liquid depths 1:C�---- Capacity4.1— I Disposal Field: Distance from nearest wellTQ-----Distance from foundati j Dy�stance to nearest lot i � I --, ----------- �j�----=---------- Number of lines_________ _._. --------- __Length of each line.- Width of trench_.__ t-___ Type of filter maters -D �_____________ --- ------------ epth of filter material___---�--�------_._Total length-----------,�-��--��- ----------.--- Seepage Pit: Distance to nearest well..___________--------Distance from foundation--------------------Distance to nearest lot line_____._._-.- ❑ Number of pits----------------------Lining material-----------------------Size: Diameter-----------------------Depth------ ---------- 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_____.______-___________ (�y - - a Distance to nearest lot line____________________________________ Remodeling and/or repairing fdescribe):--------------------------------------------- -------------------------------------------------------------------------------------- -----------------------------------------•---•---------•--------------------••-------•--------------------------------------------------------- -------------------------------------------------------------- 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)__,�._ ------------- ----------(Owner and/or Contractor) By z •+- (Title) -------------------------------------;-.--.-•-------:----------------- ------ - ------- (Plot plan, Showing size of to location of system in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY -------- ---------------------------------------------------------------------- DAT �.. __ REVIEWED BY ------ ----- DATE_ ` BUILDING PERMIT ISSUED------------------------- ---------------------------------------------------•- ---_ DATE--- --------------- -- Alterations and/or recommendations:----------------------- " -•--------------------------------------------•-------. --- -- -------------- ---.--- ... _'_--• `y` -----. -.---- --------- -------------- ---------—S ' , ^- FINAL INSPECTION BY---------------------- --------- Date -------------------------------------------------------- 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-11-2M 10-52 Revised W-2100