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Sy APPLICATION FOR SANITATION PERMIT Permif Nc,3.---------------- • ;� Va (Complete in Duplicate) Date Issued . ---,J- 3 Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described. This applicationP is made in compliance with County Ordinance No. 549. 2t/S Td Al JOB ADD 5S ND LOCATION__--_ ��r�---- /,Pasa 4D JZ m D0 ------- ------------- ------------- -------- Phone------------------------------------ ------------------------ -•-•- vn/3 T4 N------•- --------••--------•----------•-------•------------------- _ _ ---------- 77A_61 �a------ --------------- Phone I T gyp: Contractor's Name_______�J-s---�`--- ------ - - Commercial ❑ Trailer Court ❑ Motel ❑ Other E]Installation will serve: Residence {� Apartment House [I1 �-1 • -- I . 7 Number of living units: --J-- umber of bedrooms _:�Number of baths ---- Lot size - 7.6 ---'x Water Supply: Public system ommunity system ❑ Private ❑ Depth to Water Table o ft. 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 El No [1 TYPE OF INSTALLATION AND SPECIFICATIONS: (Nd septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tank: Distance from nearest well-----------------Distance from foundation_ ' __ Material-------=- No. of compartments------ ------------------Size--------------- lqu� �ePth__ -Capacity F1 IZN Disposal Field: Distance from nearest well-----------------Distance from foundation______________------Distance to nearest lot line----------------- ❑ Number of lines------------------ ----------------Length of each line-----------------------------.Width of trench----------------------------------- QQ $ Type of filter material-------.------------------Depth of filter material-------------------- �-Total length--------•---------------- Seepage Pit: Distance to nearest well__ Q -Distance from foundst __.__..Dis#ance to nearest lot line_._ ` C �'� ze: _ ..�� Depth---- - `_ .^� Number of pits--------I------------Lining material r _, � Cesspool; Distance from nearest well_________________Distance from foundation._--_..------_------Lining material--------__,________.___-_____---__ -. ❑ -Depth Liquid Capacity gals. Size: Diameter------------------------------ Privy: Distance from nearest well---------------------------------- ------Distance from nearest building--------------------------------------- -- ------------------------•-__------------------------------------------ ❑ Distance to nearest lot line-----------------------------------------------------------------------Remodeling and/or repairing (describe)_________________.._- ---------------------- --------------------------------------- -------- -------------------------------------------------- ------------------------ ----------------------------------------- ---------------•-------- I hereby certify that I'haverk:,prepared +his application and that the wowifl-lie 'done in accordance with San Joaquin County r ordinances, State laws, and rules-and.,regulations of the San Joaquin Local Health District. �f - tr Contractor) (Signed)----- -•--- -�- --- -- ------------- (Title)- - - -- --- -------------------------------------------------- - (Plot plan, showing size of lot, location of sys+em in relation to wells, buildings, etc., can be plated o eversa side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY--------------------------- ----- - ------------•---- DATE-------------j 2 3- - - ---------------- ------------ - - -- = DATE---------------' REVIEWEDBY-----------•----------------- -- BUILDING PERMIT ISSUED------------------------------------- ------ •- -------•--------------------------------------- --- DATE--------------------------------------------------- - --- Alterafions and/or recommendations:----------------- --------- __ -------------- --•-•-------------------- -- FINAL INSPECTION BY:._. _----- 1 Date ----- SAN JOAQUIN LOCAL HEALTH DISTRI T 300 West Oak Street [32 Sycamore Street 814 North "C" 54ree+� 130 South American Street Trac Califam�+ia Stockton, California Lodi, California Manteca, California Y. ES-9-2M 10-52 Revised W-2100