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V,r APPLICATION FOR SANITATION PERMIT Permit No. .__ _3 (Complete in Duplicate) s Date Issued 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 AN LOCATION--------- .1 ---------- ,-y Owner's Name. v -- ---- - ------•-- ------------- ----------- --- -------------- -- ------ Phone------------------------------------ Address---------------s� �� --- --- Contractor's Name ! - ----- --- •-------------------------------- Phone-- 4__ Installation will serve: Residence 54 Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: I------ Number of bedrooms - -- Number of baths ./____ Lot size -___----4--- -_-_ --- - -------- 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 IN Hardpan ❑ Previous Application Made: Yes ❑ No ❑ New Construction: Yes ❑ No Ik TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if. public sewer is available within 200 feet.) from nearest well -./�� Distance from foundation--------------------Material_____..___----------- ._______-________._---_-._Septic Tank: J�g e "�:- f® NcompartmentsLiquid de th-.-.------:----.---------_Capacity . Disposal Field: Atice from nearest well-----------------Distance from foundation-------------------_Distance to nearest lot line----------------- Nu er of lines---------------------:--...___--Length of each line-----_----.-----------..---.-.Width of french----------------------------------- Ty e of filter material.........................Depth of filter material---.._____.___._.._._--Total length----..__-_____________--_____________ Seepage Pit: Distance to nearest well....A/_4---distance om founds i n__ _�_---+__.Distance to nearest lot line__a_Q-0-�_ ] Number of pits..-.--./-------------Lining material__- - ._0-��_��Z�Pneter--------5�0_��----Depth...------�d-�-------------- Cesspool: Distance from nearest welf-----------------Distance from foundation--------------------Lining material _-----.._______..__.__ \ ❑ Size: Diameter---- ---- -------- ------ ----..Depth------ --------------------------------------------Liquid Capacity------------------------_--gals. Privy: Distance from nearest well-------------------------------------------------Distance from nearest building------------------------ ❑ Distance to nearest lot line--------------- ---------------------------------------------------------------------------------------- Remodeling -------------------------------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, St ws, and rules and regulations of the San Joaquin Local Health District. (Signed)_ �- --- - --- - - ----------------- -------_--- --------------------------------------- ----------- [Owner and/or Contractor) By: "_ ---------------------------- -•-- (T.------.. itle c��.^"'�f )----- (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_._. ,C <_ --------- ---- ------ ----- I-------------------------- DATE------_�-- REVIEWEDBY----------------------------- - -------------------- ---- DATE---------------- 1._ �-L------------- �p-------------------------------- BUILDING PERMIT ISSUED----------- ---- ----------------------------------------------------------------------------------- -• DATE-- ---------- --- � Alterations and/or recommendations-------------------------------- ------- ---- -------------------------------------------------------------•------- �3_.....------. -------------------------------•-------------------- -----••------------ -----------------------------------------•--•-----•-------------•-------------------•--••-----------------.----•----------------------------- ------ -------------------------------------•------------- -•------------------------------ -------------• ------------------------------------------------------------------- •----------------.... ------------------------------------------- -•------- ------------- --- -- --------------------------------------------------------------------------------------------------------------------------------------- -- 1 b F1NAL INSPECTION BY ...--- -------------.------------------------...__....... Date-------'_c__---- ------ -----• ......... -- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Sires! 300 West Oak Street 132 Sycamore Street 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California E�9-2M ,asaa5 nTw000 ,z-sa !04