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APPLICATION FOR SANITATION PERMIT Permit No. ---- (Complete in Duplicate) - Date Issued ___�Q��___ Applica+ion 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. S49 2-2_3- 14.3 JOB ADDRESS AND LOCATIO _1'S� r��-� d _3__ .�f__��_ -�-_/11a_ _ Ow s ame------------- . - •! = --------- Phone----------------------------------- a -----------=-------- Address----------------------------------------• Contractor's Name------------------------------------------------------------------------------------------------------------- ---------------------•------- Phone-------------------•-------------- Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: 1_____ Number of bedrooms -5-- Number of baths ._Z__ Lot size __.___X_ � _ ----------------- Water Supply: Public system [] Community system ❑ Private Depth to Water Table 4'!ff. Character of soil to a depth of 3 feet: Sand ❑ Grave! ❑ 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 feet.) Septic Tank: Distance from nearest well_- (--' --Distance from fountionlA- -----------M atyrial _ ® No. of compartments- .-;�- ..........Size- _ .._Size_ _Q___tC_�f 4X___�___--Liquid depth . _- p a ____Ca cit d Y ---------- 01 Disposal Field: Distance from nearest welt--5Q--47�Distance from foundat�q�?_ '""""~�-,(�istance to nearest lot line__S__'''+rv�•w Number of lines___.--_ ___-. Length of each line: �y "� ® --- - 9 ��--J- 7�._ _`.��_.Width of trench---��------------------------ Type of filter maferial___s-,_ ,,__ _ ._ Depth 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 nearesf-well-------------------------------.-----------------Distance from nearest building----------------------------------------- F-1 Distance to nearest.lof line----- - ----- - -------------•----------------------------------•----•---------------------------------------------------------------------- +T�nr - Rain ----------- + f -Lte - lrr+g� yf,�1F v_..fir +.% �•----------- ----------------------- ------------------------------------- ------•---------------------------------------------------------------------------- --------------------------------------------------------------------------- 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, nd rules and regulations of the San Joaquin Local Health District. --{aC - .......... s _________________:__.__-_-(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). FORtgARTMENT k ONLY APPLICATION ACCEPTED BY---- ---- ------------ `. DATE . REVIEWED 'BY--------------------------------------------- --------- ----------------------------•--------------------------------------._ DATE BUILDING PERMIT ISSUED------------- ------•------------------------------------------ -- ---------------------------------- DATE.--- Alterations and/or recommendations:--------------------- ------ - -- ----------------------•---------------------•-----------------------•-------------•--•---- ----------------------------------------------------------- -----:--•---------------------------------------------------- ------------------- ------ - -----------------•--------- - FINAL INSPECTION BY:.---- - - - -- _ ----------- ------ Date---------- --- --' SAN JOAQUIN LOCAL HEALTH DISTRICT w 130 South American Street 300 West Oak Street 132 Sycamore Sfreet 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California ES--9-2M 145446 ATWOO❑ 12.54