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APPLICATION FOR SANITATION PERMIT Permit No.3_j�_7_0------ (Complete in Duplicate) Date Issued 7 Application 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 compliancewip County Ordinance No. 549, I N --- ----> _ JOB ADDRESS AND LOCAT 0 --- --- -P- - -- Owner's Name �--------------------- Contractor's - - - -----I---— --------------P--h--o--n-e------- Address-_--------------3_&-------- ------- -----Name-------------- - - -- - - --------------------------------------------------------7------------------------------------------- -----------------------j-----7---- ----- - Phone-------------------- _------------ Installation will serve: Residence partmerif House E] Commercial E] Trailer Court E] Motel [] Other E] Number of living units: ----�N mber of bedrooms ---WNumber of baths ---I---- Lot size -------------- Water Supply: Public system C1. Community system '[:] Private x Depth to Wafer Table�o___it. M.-4— ^; cnil +n a depth of 3 feet: Sand 0 Gravel 0- Sandy Loam [I Clay Loam Clay ❑ Adobe 0 Hardpan ❑ Previous Application Made: Yes E] No X New Construction: Yes CK No F] 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 Sbt Distance fro rr foundation____----10----------M a te r i a I _L oun( -- - ------------- ---- -------------- No. of compartments--------;--------------Size___,3__X__T__X__S._Liquid depth--------4--------------Capacity.... Disposal Field- Distance from nearest well-46_0______-Distance Distance from foundation----A-0------Distance to nearest lot line---- Number of lines------------I--- ----------- -Length of each line----------6--0--ff------Width of trench_____3_0------------------ Type of filter material---ST- - -------:Depth of filter maferial-------/S----------Total length_____1_X_0------------------------ Seepage Pit: Distance to nearest well----------------------Distance from foundation--------------------Distance to nearest lot line_________________�� [] ine----------------- El Number of pits----------------------Lining material-------_---------------Size: Diameter----------------------_Depth------------------------ _--_. Cesspool: epth------------------------------- Cesspool: Distance from nearest well------------------Distance from foundation--------------------Lining material_______---------_-------------------, ❑ aterial-------------------------------------- El Size: Diameter--------------------------------------Depth----------------------------------------------------Liquid Capacity------------ -- gals.. Privy: Distance from nearest well______________ _____________________________Distance from nearest building-___._-__---❑ Distance to nearest lot line--------------------------------------------------------------------------------------------------------------------------------------------- Remodeling and/or repairing (describe):----- ------ --------- 1K4------' K 4------ ---------- ------ -- ----- ------- - --- ---- ------- --------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- 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 regulations of the San Joaquin Local Health District. (Signed ------ -------- -------------------------------------------------------------------(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). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY---------------------------- A -- -------------------------------------------- DATE ,-. Le-------------------------- ------------- REVIEWED BY--------------------------------- DATE--V ------------------------------- BUILDING PERMIT ISSUED ---------------------------------------------------------------- DATE------------------------------------------------------ Alterations and/or recommendations----------- ---------:----------------- ------------------------------------------------------------------------------------------------------------------------ ---------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------ -------------------------------------------------------------------------------------------------------- ------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ ---------------------------------------------------------------------------------------------------------------- ---------------------------------------------------------------------------------------------- -------------- Date Date----------A-_ INSPECTION BY:--------------------------------------------------------------- --- -------------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oat Street 132 Sycamore Street 814 North "C" Street Stockton. California Lodi, California Manteca, California Tracy, California ES-9-2M B-51 Revised W-2100