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APPLICATION FOR SANITATION PERMIT Permit No. ` (Complete in Duplicate) V� Date Issued Application is hereby made to the San Joaquin Local Health District for a permit to cos �nd install the work herein described. This application is made in compliance with County Ordinance No. 549. - U 3 $_--: � -c _ ------------------------ JOB ADDRESS AND LOCATION_.____ �t 0----------- ---- :.�- - -•----• --- Owner's Name-- ----- Address-----------------------3--Q... C� S ' _ Contractor's Name-------- - -' '------- Phone------------------------------------ Installation -----------------•------------ -------------------------------------------- Installation will serve: Residence Edi-Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: -------- Number of bedrooms -------- Number of baths -------- Lot size __ �__X___J,5 ----------------------------- Water Supply: Public system ❑ Community system '❑ Private &e"Depth to Water Table ..------ ft. Character of soil to a depth of 3 feet: S;�ONew Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe❑ Hardpan2--,-- Previous Application Made: Yes E] No Construction: Yes ER" 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--------------------Material-------------------------------------_____._____. ❑ No. of compartments--------------------------Size--------------------------------Liquid depth-------------------------Capacity-------------- W Disposal Field: Distance from nearest well_________________Distance from foundation_:____.________--___Distance to nearest lot line--------------_-- ❑ Number of lines-----------------------------------Length of each line------------------------------Width of trench----------------------------------- Type of filter material_________________________Depth of filter material-----------------------Total length--_____-___---__--____-_____-- _-_._-- Seepage Pit: Distance to nearest well----------------------Distance from foundation....................Distance to nearest lot line----------------- El Number of pits----------------------Lining material-----------------------Size: Diameter-_____-..___________--_.Depth--------------------------------- r Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material----------------------------------- ❑ Size: Diameter--------------------------------------Depth---------------------------------------------------Liquid Capacity-------------------------- gals. ww ______________Distance from nearest building Privy: / Distance from nearest well--------,tJ.---------- •__ ___ 9--------- 6_0------------------------- [� Distance to nearest lot line------------ --------- 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 ws, and rules and�reg ons of the San Joaquin Local Health District. (Signed)_ - --- L'= °y „/----------------------------------------------------------------------------(Owner and/or Contractor) yg }. By=----- �`, ,=- t _r..-------<1- ...... Z -.-------------- -- (Title) = - (Plot plan, showing size of I , location of system in recon to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY ' =r Y ------ DATE_ _ /. j° ------------------------- _19tAPPLICATION ACCEPTED BY__ ---` '- ---- --- = ?� REVIEWEDBY-------------------------------------------------6)------------------------- DATE------------------------------------------------------------ BUILDING - ------------------------------ BUILDINGPERMIT ISSUED------------------------------------------------------------------------------------------------------ DATE------------------------------------------------------------- Alterationsand/or recommendations---------------------------------------------------------------------------------------------------------------------------------------------;;--------------- ----- -- ------------------------------------------------------------------------------ ---- - -------- ------- ------- i---- , t- -- ---------------- -- - -- i---- - -- ' k `' - --- FINAL INSPECTION BY----- ----- -- ------ --- --- ----------- ----- Date----- - - - --{,{ - 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 fro ES-9-2M 8-51 Revised W-2100