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v 5 APPLICATION FOR SANITATION PERMIT Permit No: -_2_3.Sh_:.3_-_ . (Complete in Duplicate) 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 AND LOCATI N---.�._3_1- r r,,•: --------------------------- � n Owner's Name---------- ..~ '�. ------------------------------------' ------------'-----------'---------- -. Phone--,�-_.-�--�-�-�---------- Contractor's Name_ Phone., =-I_-W ! Installation will serve: Residence ® Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: _ __ Number of bedrooms __. Number of baths __a_. Lot sizen_I rp__----------------------------- Water Supply: Public system ❑ Corimmunity system ❑—PiFivate'® Depth to'Water`Table Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑M Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe © Hardpan ❑ Previous Application Made: Yes ❑ Nb ❑ New Construction: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: 4 1 (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tank: •v( Distance from nearest well_________________Distance from foundation--------------- Material----------------------------------------.-______- [J Fx No. of compartment - ----------------------- ---------------------Size..t----------------- ---.---Liquid depth----3-------- -----------'Capacity---------------------- I. t I IYr r i' Disposal Field:. Distance from nearestiwell___7_ Distanee from foundation---/f3------------Distance to nearest lot �r lines line. 4d_ ___.._ Number oz -----:!.�3------------------Length of each line_____-_o2_d__`------.----.Width of trench_-----�- l- ------ i rr{ Type of filter m -_ __. Depth'of filter material___ lTostal length_____"_(,_P------------------_________ Seepageline VV Pit: Distance to nearest well,____._-_____________Distance from foundation____.-_.____...__. Distance to'nearest lot line__---_________.._ --- ❑ Number of pits---------------------Lining material-----------------------Size: Diameter----••------------------Dept h----------_------------_-------- ± Cesspool: Distance from near#s't well______________'_Distance from foundation._..______________.Lining material_____________-.___:_____.__.__".._. 1 � Size: Diameter------ -= -------------------------'-Depth .,'_ -�--"=="-R � . _". Liqu"id Capacity . . - - -gals. Privy: Distance from nearest well_____________ _______________________-_._--._Distance from nearesr building._________.________________-----------. ❑ ° # ----- ------- -------------------------------------Distance to nearest lot-line-, ' ' Remodeling and/or repairing (clescribe)%_ J - _. --- - ---.. - - I x". i f --------------------------------------------------------------------- �. f f i3 I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances Se Se laws, rid s and regulations of the San Joaquin Local Health District. t (Signed)-___._ ____'____ ___L_. _". Owner nd/or Contractor] --1.------'~�---- -- ._—..-(Title)--`" (Plot plan, showing size of lot, location of system in I lation to wells, buildings, etc., can be placed on reverse side). t FOR DEPARTMENT UE ONLY APPLICATION ACCEPTED B ; = s 4 DATE. I REVIEWED BY------- - DATE----- ----- BUILDINGPERMIT ISSUED------------------- ------------- --------------------------- ---------------------- ---• ----------- DATE----- ----�-----' Alterations and/or recommendations:----i=n_-_+_------- _ _--_- _- ___-------------_--- r i -------- ------------------------------------- -------- ------------------------------------------- ----------------------------------------------------------------------•-------•-----"--------------------------------- ---------------------------------------------------------------------------------------------------------------------------- •-----------• -----------------------------------------•--------------------------------------- ------------------------------------------------------------------- -------------------------------------------- --- ---------- --------------------------------- ---------------------------------------------------------- ----------------------------------------------------------------------------------------------------------- ----- ,l FINAL INSPECTION BY-----------�1 ----- _}� -_F'._ - ..........._. Date_---------- SAN JOAQUIN LOCAL HEALTH DISTRICT _ w - 130 South American Sfree+ 300 West Oak Street 132 Sycamore Street 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California 7 , E$-9-21v1 10-52 Revised W-2100 � �" d.::_=