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APPLICATION FOR SANITATION PERMIT Permit No.(,:r�_ (Complete in Duplicate) 641 f�3 Date issue r 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 compliance with County Ordinance No. 549. JOB ADDRESS AND, LOCATION------ �3D.-- -- Owner's Name - - � :: t � Phone --•--- � ^ ... �� Address ��1 `,' : .. 4 Contractor's Name ..__ Phone,60�-.._-�.�_.��--_-��------ j Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living"units: ---- Number of bedrooms _L�__ Number of baths __J_.. Lot size -------------------•- Water Supply: Public system Community system ❑ Private ❑ Depth to Water TableZT�-Ift- Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay [❑ Adobe Hardpan ❑ Previous Application Made: Yes ❑ No`- New Construction: Yes,K No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: {No septic tank or cesspool permitted if public sewer is available within 200 feet.} r Septic TeF - Distance from nearest well___________ ____Distance from foundation-------------------Material--------------------__------_____________._. No. of compartments -----------=- - ------- 4, ----- Size Liquid depth _-Capacity � 'V is0os I i : Distance from nearest well. .______Distance from foundation___________________Distance to nearest lot line_____________---. I Number of lines. -----------Length of each line------------------------------Width of tranch.._._____.____.______.________-- 61, Type of filter material-------------------------Depth of filter material----,_:" -----___----Total length---------------------------------------- Seepage ---------------------------------------See a e Pit: Distance to nearest _'__Distance f m fo dation __..0.___.Disf�ance to nearest lot line. t�.__ ___.- Number of pits-__._. -_________Lining material -t,f.Size: iameter___. .________.Deptn____ _ ___________________ �°` Cesspool: Distance from nearest well-----------------Distance from foundation___-..--------------Lining material------------------------------------ El Size. Diameter--- :----------Depth----------------------------------------------------Liquid Capacity------------------ gals. Privy: Distance from nearest well---------------_----------------------------------Distance from nearest building--------------------------___----_..____--- ❑ Distance to nearest lot line._.__ -----------_-�.______._ ---------------------- - ---- 19 4 "-" --- ------ --- �1 �+�°'�°.`w �.a� "- ----- =------ Remod ng and/or repairing describe]:______ -,__ __ _ _ - .• - --------------•---------------------- ------------------•-------------- $ . ! ---------- � �., --- ---------- Y -•-----------------•--------------------------------------------------•-- ------------- - -1 hereby certify +ha+ I have prepared +hi_.application and that the work will be done in accordance with San Joaquin County ordinances, Sate laws, an $Toles d regula4ions of the San Joaquin Local Health District. --------- (Sign -- , Y•° - -----__-"---- - -_ ____--_(Owner and/or Contractor) Y� = A= {Title ---------------- ---------------------------------------- B (Plot plan, showing size of 1 , location of system in relation to wells, buildings, etc., can be pl don reverse si FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY----------------- - ' DATE____-- _ •� -- --- REVIEWEDBY-------------------------------- ------ F -•----------------------------------- DATE -- `" .._...-•• BUILDINGPERMIT ISSUED---------------- -------------- -------- ' ---------------`DATE-------------------------------- ----- ------------------ Alterations and/or recommendations:______________________ __ ---------------•---------------•---•-- ------•-------------------------------------------------------------------------------------------------------------•------••---------•----------------------------------------- r . .I 4 =- ---------- -------------••------------------------------------------------------------------------------------------ FINAL INSPECTION BY:.... Date `--� --------------------------- or SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West:!Oalt Street 132 Sycamore Street 814"North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California ES-9--2M 10-52 Revised W-2100