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k - ' �✓ APPLICATION FOR SANITATION PERMIT Permit No. 3 __? _____ 1 (Complete in Duplicate) C� 1 Date IssuedI. ) - - Application 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 No. 549. JOSADDRESS AND LOCATION ------w------- - --------- --------------4-------------------------------------------------------------------- Owner's Name------------ ` '+ ---- 1-:51 ---------- --------------------------------- Phone -------- Address------------------- j- -- -------------------------------------------------------- s Contractor's Name-- " f.... r _�'{----- !' ------ Phone-- .�_��_�`. Installation will serve: Residence'�artment House ❑ Commercial ❑ Trailer Court ❑ Mote �l 0 Other E]Number of living units: __�___ tuber of bedrooms _a-_ Number of baths --/-. Lot size ----jW ------ ------------------ Water Supply: Public system Community system ❑ Private ❑ Depth to Water Tabl,.Z ft. Character of soil to a depth of 3 feet: Sand [],.,Gravel ❑ Sandy Loam ❑ lay Loam ❑ Clay ❑ Adobeardpan ❑ Previous Application Made: Yes 0 No [booeNew 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 well________________Distance from foundation-------------------.Material - -_---- ___________.________:_______________- ❑ o. of compartments---- --------------------5 -- -------Liquid depth----------------------=---Capacity----------- ``---------- Disposal Field: Distance from nearest �._ _ _. ._ stance from foundatioq___�a.____-Distance to nearest lot line__!-��_______ ❑ �` Number of lines_______ 4-t:yam__.__ _Length of each line--------?a—____��__-Width of trench__�______________________ ! Type of filter material__------_.Depth of filter material-----/,`---------Total length___.._.�___ _________________ Seepage Pi : Distance to nearest well_A/A_ Distance from.foun ation___� -------DisZpe to nearest lot line__/Q__-- Number of pits__ a- _______Lining material_ _ ___%Size: Diameter------ Dept h______�5__ --------------- 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 " ---------------------------------------------- ------------------- -------i;;.1- --------------- - 11 Remodeling and/or repairing (describe):---------- _ ___ _ ____________ ___ __ -------------------------------- --------------- ------ -- - r s =� - ---------. ----------------------------------- ----------------------- ---------------------------------------------- I hereby certify that I have prepared this application and that the work will be done i accordance with San Joaquin County ordinances, State laws, and rules and re ulations of the San Joaquin Local Health D'strict. f +� "' - - �Y.11LAI'4 F - Owner or C trac+or) (Signed) BY� `' - -=----------------------------------------- (Title ------------------ -------- x _ I (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). I FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY ! __l' -s -------- DATE-----y 7-- I REVIEWEDBY--------------------------------- -------------------------------------------------------------------------------------------- DATE------------------------------------------------------------ BUILDINGPERMIT ISSUED----------------------------------------------------------------------------------------- --------- DATE--------------------------------------------------.---------- Alterationsand/or recommendations-----=--------------------- ----------------------------------------------------------------------•--------------------------••--------------------------------- -----•-•--------------------------------------------- ------------------------------------------------------ -------------------------------------------------------------------------------------------•-------------------- --- ---------•--------------------•-----------------------------------------------------------------------------------------------------------,--------------------------------•---------•----- -•------- -------------- ------------- -------- - ------------------------------------------------------------------------ ------------------------------------------------------------------------------------- ww FINAL INSPECTION BY: ,I� ------------- 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-9-2M 8-51 Revised W-2100 C