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Permit No. ... _�__ -3 APPLICATION FOR SANITATION PERMIT (Complete in Duplicate) Z� Date Issued Application is hereby made to the San Joaquin Local Health District for a permit t6 constrgcj nd nstall the work herein described. This application is made in compliance with County Or No. 549. 'JOB ADDRESS AND LOCATION-------` -------�_°��e C r� 77 Owner's Name-----------------—----'-------------'•-•M-'•------- {M --7. ----- Phone--------------------•--------------- Address--------------................................. �--I/-�--------------------------------------------------------------------------------- --------------.. --------- -------------------------- Contractor's Name-----------------------------------A74.9-A�<--------------------------------------------------------------------------------- Phone----------------------------------- Installation will serve: Residence Apartment House ❑ Commercial E] Tray er Court L] Motel ❑ Other E]Number of living units: _ Number of bedrooms 1. Number of baths _i----- Lot size -----7jr_k---f_I_2-------------------------- Water Supply: Public system[ Community system ❑ Private ❑ Depth to Water Table -------- ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe, ( Hardpan ❑ Previous Application Made: Yes X No ❑ New Construction: Yes X 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 foundation----1a---------Mat� I---f--- f". ----------- cit ___._-No. of compartments__._--.-__ ----------Size--- Liquid depth--------- �_;1...--Capy ---- osal Field: Distance from nearest wO------~'-----.Distance from foundation----?4_f_______-Distance to nearest lot line----- -_____ Number of tines__________ R..—� __Length of each line_________-- --------Width of trench..--__-.._-•�__WP_.---__._.__ PType of filter material_ _._..Depth of filter material---..____/. ��------Total length-----------------1o0__-__-__-___-- Seepage Pit: Distance to nearest well----------------------Distance from foundation--------------------Distance to nearest lot line----------------- Ch ❑ Number of pits----------------------Lining material-----------------------Size: Diameter-----------------------Depth____..._______..____---_-..------ Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material____________________-__--__--._._-_ ❑ Size: Diameter--------------------------- ----------Depth----------------------------------------------------Liquid Capacity----------------------------gals, Ch Privy: Distance from nearest well----------------------------------- _____________Distance from nearest building---------------------------------..__..._. ❑ Distance to nearest lot line----------------------------------------------- --------------------------------------------------------------- -------------------------- (T Remodeling and/or repairing (describe)__________________ __ �� -------------------•----------•----------------------------------••-----•--------------•--------------•-----------------------------------•-------••---------------------------------•-•-•--------------------------•--------- - ----------•-•---------------------------------------------------•------------------------------------------ --- -- --- --------- ------------- - 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 rule and regulations of the San Joaquin Local Health District. (Signed)__ r r l! � eE� ' f�------------------------------- -(Owner and/or Contractor) B (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----- �}, -- REVIEWEDBY - - ----------------------------------------------------------•---- DATE ---- ------••--------------------------- BUILDING PERMIT ISSUED-------------- ------ DATE------------------------------------------------------------ Alterationsand/or recommendations------------------------- --------- ---- ---------------------------------------------------------------------------------•-•---------------------------- ---------------------------------------------------------------------- ------------------------------ ------------------------------------•-------- ------------------------------------------------•-•--•-------------------- --•----------- ----------------------- ------------------------------------------•----------------- ----------------------------------------------------------------------------------------------------------••----- - -------------------------------------- - ---- --------------------------------------- -------- --------------- ------------------------------------- FINAL INSPECTION BY-.-------,ellzllek - Date------------j p ----------------------------- 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 E5-9-2M 10-52 Revised W-2100