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APPLICATION FOR SANITATION PERMIT Permit No. _-3 U Y (Complete in Duplicate) Date Issue -• ? -S�J� Applica4-ion 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_________Sa3•._ *____ __ —12 " Owner's Name---- /1-@'1z t? � ------------------------------------------- --------.- Phone.__/I'll- .71-7----- Address......... --------------•--------.....------------•------------------------•----------------------------------------------•------- Contractor's Name........J�__,o__... _ _______________ Phone___/-_77a:_'?/a_A_x'_.6----- Installation will serve: Residence Tr-'Apartment House ❑ Commercial ❑ Trailer Court ❑ //Motel ❑ Other F]Number of living units: _-/___ Number of bedrooms ___�_ Number of baths J... Lot size ____4��___,_xw!!_------------------------- Water Supply: Public system Community system ❑ Private ❑ Depth to Water Table :!�r ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe[ ardpan ❑ Previous Application Made: Yes ❑ No [!t New Construction: Yes (rIq-o ❑ 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------Ce ___-_-_ -------- ---------- No. of compartments_____ v2 -__________Size_J'r__6___X 44..4-..........Liquid depth........ ______Capacity_ D-- -- i Disposal �Id: Distance from nearest well��-_.Distance from foundation___��__--------Distance to nearest lot line-----------s_ ❑/ Number of lines--------- _______________________Length of each line__,-,�4Q_----------------Width of french. _.___.�y�'___---__________ S!- Type of filter material_- _!RO c!�__Depth of filter material.. �g��________Total length.......�a _�_____________________ ^ �� Seepage it: Distance to nearest well-- _Distance from foundation.---.3.4-_____________Distance to nearest lot line----- ._S____.____._ l Number of pits-----Z-------------Lining mate ria l.,0X8_-/4?Dc*.Size: Diameter......... -..-____.Depth------- _______________ Cesspool: Distance from nearest„well---------------- Distance from foundation----_---------------Lining material_____________________________________. ❑ Size: Diameter------------------------------ -------Depth---------------------------------- -..........Liquid Capacity---------------------------gals. Privy: Distance from nearest well---------------------------_---------------------Distance from nearest building------------------------------------------ F-1 Distance to neare lot line-------------------- ---------- - -- ---- ------------------------------------------------------------ ----•-- -•---------------- Remodeling and/or repairing (describe):-----------------------------------------•----------------------- -----••--•------•-•--••-----------------•---------------------------------••---•--•- �b --•-----------------------------•--------•--•---------------------------------•--------- ------------------------------------------------------------------------------------------------------•--------------------------- --•--•-•----•--------••---••••-••--•••--••--••-•-----•--••••----••---•--------•-•••-••---•-•-•-•------•------------••-------••-•--•----------•---•-••--•-•-••----•--••-•-••-----•-•----••------------•----•-------••-_... ------------------------------------------------------•-------------------------------------------=-------------------------------------------------------•----- ------ I hereby certify that I have prepared this application and that the work will .be done in accordance with San Joaquin County ordinances, State laws, and rules and regulations of fha San Joaquin Local Health District. Si ned ' ( 9 )--•----- -------------------------------------------------- ---(Ow and/or Contract) By: �-� � = `' (Title) --------- -- �j-'r'Z'` (Plot plan,showing size of lot, location of system i elation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY P. APPLICATION ACCEPTED BY...._ _- - --,__-- ------ DATE____ _7 _. ----•---------------------- REVIEWEDBY.......................------------------------------------------------ ---------------- ----••--•---------------•-••• DATE............................................................ BUILDING PERMIT ISSUED------------------------------------------------------ ------------------------------------------ DATE.............................. .............................. Alterations and/or recommendations:-------------- _ ----- ----------------- -----------------------------•-------- ------------------------------------- - - -�-7--------------------- ==-----•--.. -----------------••----•----------•-••----•----••------------------•••----•------•---------•-----------------•••••••--••-------------•------••-------•••••----....__•-----••--•--•-•-•--••---•-----•••••-----•--•--••-- ----------------------------------------------•- ..--.-.-•---------••-•--------•-•-••••------------------------•-•---•--••••••------------•----•----------•-•---•_-••-•----•-------••--------•---•--•-----------•---•-•-•---- ------------------•------------------ --------------------------•-------•------------------------------------- -----------------------------•--------------------------------------------•------------------------------ FINAL INSPECTION BY:-------------- �1... �Vll Date DtG �LS f-� - - ...................................................... SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Street 914 North "C”Street Stockton, California Lodi, California Manteca, California Tracy, California ES-9-2M Revised W-2100