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APPLICATION FOR SANITATION PERMIT Permit No. 3 (Complete in Duplicate) ' Date Issued Applica+ion is hereby made to the San Joaquin Local Health District for permit to construct and install the work herein described. This application is made in c pliance with County Ordinance No. 549. ,106 ADDRESS AND LOGfaA4� O !�_ "" "._" ---------4- - ------ .�Owner's Name------------------_ . f z- -�------------ Address - - ----------------------------------- Phone_ _� 'v y --- / Address------------------------------------•-------- �.�...��_ r ------•�---------- --1---.sl-•---- Contractor's Name---- _-•---- ---�jJ f Phone--- ' s------ � Installation will serve: Residence W4partment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other El Number of living units: ---A- Number of bedrooms _ -___.-- Number of baths -_-/ Lot size ._�� 'y--�-------1-��---- ----"__"-- Water Supply: Public-system �ommunity system ❑ Private ❑ Depth to Water Table{1$ Character'of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Cla ^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 s wer is available within 200 feet.) Septic T Distance from noarest wellll sff -------Distance from foundation__ ----------------Material----�- •4�--- - -----------• No. of compartments---- ---------------Size_,J``�` 3V_,,C�_w3_1iquid depth_ --------------Capa Pity. Gj Disposal F"eld: Distance from nearest weff.�l`(o�.��.-Distance from foundation_K•__""_G "_Distance to nearest lot line Number of lines--------L--- --- --------- -----Length of each line-----"-----------------------Width of trench_.2.7`?,____7.__._."_.__-"""- Type or filter material__--fir`"-___"l.- p ! De th of filter material__ ----------------- ----------Total length-------••-----------•---------------- Seepage • : 'Distance to nearest well" J Distance Ir f ndation---________________ Distance to nearest lot line ��_`~ its..-+/ Number of p _ Li ___ ning material_ _1".r•+;----Size: Diameter...,....3-__ p s� , -- f Cesspool: Distance from nearest well-----------------Distance from foundation-__________._-____.Lining material---------'--------------------------- ❑ Size: Diameter--------------- -------------------Depth' Privy: Dis'fance from nearest well---------- - --------- Liquid Capacity r gals. _______ ._______.-_--.___-----Distance from nearest building = Distance to nearest ----------------- -----"--- _. ------- =------------- Remodeling and/or repairing (describe):__---__o-.`-..___----- � i x --------------------------------=-----•----• •-- --- ----------------"----= -- --•-------------------------------------------------------- ----------------------------------------------- ad I hereP at I have prep rthis app ication and that the work will.be done in accordance•with San Joaquin County ordinances\ and r les and gulations f the San Joaquin Local Health District. (Signed) --- - ----- Contractor) BY: - ---f --F_ (Title]_ �.�... cC tc;zn/�- (Plot plan, showing size of lot, location of system in rela on to wells, b dings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED.BY__ s - DATE_. -------•----------- REVIEWED BY ------------- -=------ - DATE__. � BUILDING PERMIT ISSUED_______________ DATE... ._ ------------------------------------------ - -•------------------------------------ :------------------------------------------------------ Alterations and/or recommendations:_._"t------------------------------------------ •-------- ---- ------------- -•----•-------- .. - --------------------- -------------------------------- ------- -•--------------------------- --------------------- FINAL-INSPECTION-BY::-_= - --------=------------------ Date.---------- 11. f SAN JOAQUIN LOCAL HEALTH DISTRICT 13Q South American Street 300 Wast Oak Street 132 Sycamore Sfreet 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California ES-9-2M Revised W2100 1r