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r I s. • APPLICATION FOR SANITATION PERMIT Permit No. 3___q"Q I�. (Complete in Duplicate) Date Issued [11 -3l$I-, Applicafion 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 No. 549. JOB ADDRESS AND LOC N---- --------- --------�------------�--�----- ---- - - - Owner's Name-------------- ------------------------------------------ --- ------------------ Phone ------------ Address_ �, ---- - ------� ------------ Contractor's Name------ --- �--'-- y _- - ----- ----- Phone__' r ------- - - '--- -----------,-- Installation will serve: Residence Apartment House ❑ ommercial [❑ Trailer.Court ❑ Motel ❑ Other p Number of living units: N er of.bedrooms ___ Number of baths' -,Lot size ------ ---�_ Water Supply: ,Public system. . : Cpmmunity system Private ❑ Depth to Water Table ft. . Character of soil to a depth of 3 feet: Sand ravel ❑t Sandy Loam p, Clay-Loam ❑ Clay E] Adobe r pan ❑ Previous Application Made: Yes El No New Construction: Yes o ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: > (No septic tank or cesspool permitted if puublic s r is available within 200 feet.) Septic Ta Distance from nearest well-440_ ____Dis#antem foundatian_- _:______.Mater• 1r . ' No. of compartments_____ ------ depth----- .lCapacity Disposal Field: Distance from neare t well/ Glf-_---Distance from foundation_�_�_-________Distance to nearest to line_ --""--"_ ❑� Number of lines___ L _ i Length of each line____-7-e`-- Width of french---�-"-_"_ , T e of fitter material_ // r_---""""" """" p� YP Depth of filter ma#erial_�-_ __"""" __Total length_____________ ---"-----_ ------- Seepage Pit; Distance to neares well ___f� -_ __Distance flr.6 - fou dation__24--_----___.Dist �e to nearest lot line_ ❑� Number of pits -----__Lining material ' _ r'Size: Diameter--- -Depth---, _________________Distance from foundation--------------------Lining _ maferial_- ___--_______-____ •�-- �� _ Size: Diameter -=--: - ---------------------------. Depth-------_:----- ----------- -----Liquid Capacity------------------------------ - Cesspool: Distance from nearest well --- gals. Privy: Distance from nearest well______________________ ____ -�' _________________-_Distance from nearest buiiding------------------------------------------- ❑ Distance to nearest lot fine__________-"""________ _____,_-"" ------ -- ------ -------- - ------------------- Remodeling and/or repairing (describe}:----__e:,OL - ----------------------- --- --_ ----_ - •- -- -- - ------------A --------------------------"""fi'-'""i'------"-----------------"---------------------------------------------------- ---------------'-----------'------------- ---------_------------------------------ -------------------------------------------------------------- ----------------------------------------------------------------------------------- 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 regulati ns of the San Joaquin Local Health Di trict, .,, (Signed)-- -- --- --- ----- r -" ="" ------ (Owner and/or Contractor) By: -A 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- REVIEWED BY �---P DATE---- 1 BUIL ---------------------------------- DING PERMIT ISSUED------ -- - -- --- - ---------- DATE `- --------------------------------- ierations and/or recomrr►endations:____________ e .------- -------------------------- ------------------------7--------------------- -------------------------------------------- -------------------------------------------------------------------------------------------------- ------------------------------------------------------------------•------- ---- - ------------------------------------------------------------- 4------------ F1NAL INSPECTION BY: -- --•-- ---------------------------------------- Da te 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 f I ES-9--2M 8-51 Revised W-2100