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APPLICATION FOR SANITATION PERMIT Permit No. ~3 (Complete in Duplicate) Date Issued �--- -----op Application is'her y 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 LOCATION------------------------------------ am--Q'"_ e-------- -- ----- ----- ------------------------------- Owner's Name ' Phone_.=3 LIq r - - Address------------•-•--_---S e l -------------•--------------=------- --••-----------------_:----- ---------------- Contractor's Name --- --- ----- -------- Phone l-l-, a �. Installation will serve: Residence K Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ k Number of living units: _./.--_ Number of bedrooms __ _ Number of baths ../__ Lot size ............. q Water Supply: Public system ❑ Community system El—Private 1 Depth' Water Table 5?_,4._ ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe)" Hardpan ❑ Previous Application Made: Yes ❑ No X New Construction: Yes No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: ►° (No septic tank or cesspool permitted if public sewer is availeb!e within 200 feet.)�� i 1 Septic Tank: Distance from nearest well---S Distance from foundation- ---a.3.+..._..Material------------------------------ --__.-....- --.-. 1 No. of compartments. 6 ' a� -------�-------- ---�-Size..��?..?��f_4--�'�-------Liquid depth- - �-�- �-------Capacity---------- - -� � Disposal Field: Distance from nearest well-"" .��.___Distance from foundation....4----_------Distance to nearest lot line-.-....------- Number of lines--------- --------------------- Length of each line-----y6________.-------.Width of trench.-------- ------------------------ Type of filter materiaL.S_J?0C C...._Depth of filter material"_-J.-.�-.-____.Total length-:------V.� `------------------------ �+ /� Seepage Pit: Distance to nearest well-_AA--..__-._Distance from foundation...__' 47......_.i!sf nce to nearest l� line................. Number of pits=------ ------------Lining material__.---_-__._---____.__Size: Diameter------ - -.Depth-----.---'�--------------------- Cesspool: Distance from nearest well--....i....---4 Distance from foundation.------------------ Lining material------------- ------ { ❑ Size: Diameter------------------ -----------------Depth--------- -------------------°-----------------Liquid Capacity----------------------------gals. Privy: Distance from nearest well---------------------------------". ...........Distance from nearest building--------.--------------------------------- --- . ❑ 'Distance fonearest lot line------------------------------F---=---------------------------------------------------------------- I i --------------- -------------- -----------------------------------------------=--------------•------------------------ Remodeling and/or repairing [describey:...._.."_............."._,_- _ -------------------------------------------- - -- -----------•---------------------------=-••---•--•--------------------------�;-----•-------------------------------------------------------------- I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County 1 ordinances, State laws, and rules and regulations of the San Joaquin Local Health District. Arr i �. r Contractor) (Signed)------------------------ ------ q3 _ caner and/o C for -------------------------------------------------- =---------------- �"n � +s (Tiitle)-- gY� �-- --------- (Plot plan, showing size of lot, locatio, of system in-relation to wells, buildings, etc., can a placed on reverse side). A_ FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY -------- DATE . -0 a :.------Z� REVIEWEDBY--------------------------------------- ---------------------------------------------------------•------------------ --- DATE---------l/------------------------------------------------ BUILDINGPERMIT ISSUED---------------------------------------------------------------------------------------- ------ DATE--------------------------- -------------------------------- Alterationsand/or recommendations:----------------- ---------------- -----------------"----------------------------------------•--•----------------.....----•--------------------•------------- -------------------------------------------------------•--------------------------- -----------------------.- •-------------------------- _ ....- .----------"....---••--------------------"----.-._..__f.-.-.._-.-....-.._._--_......------.-..._.-._.......-'-------.....---.......-.-------------------....... FINALINSPECTION BY-------------------- ------ Date.---------------- ---------------------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Street 314 North "C" Street Stockton, California Lodi, California Manfeca, California Tracy, California ES-9-2M 10-52 Revised W-2100 �"'�