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_ APPLICATION FOR SANITATION PERMIT Permit No.A3. 7_:?--____ (Complete in Duplicate) Date Issued .A .�0 . 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. A JOB ADDRESS AND LOCATION------------2-3--R---------- o Owner's Name---------------•--------- - -M_e_ .:' C = - Phone----- 11-3------- ll Address---------------------------_-7-•1Y- 6----- -------------- '" = =_ Contractor's Name--------------------------------------------------ow-------- . --- - -�-----_ --- � -- ;:---------- P� ---------------------------------- Installation will serve: Residence IV Apartment House ❑ Commercial [❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: ________ Number of bedrooms ._ ._ Number of baths .___ __ Lot size --------------i�p____1Y____/?1-__________________ Water Supply: Public system V Community system ❑ Private ❑ Depth to Water Table _yf_ ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ AdobeHardpan E]'-C Previous Application Made: Yes ❑ No New Construction: Yes No F1r TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) f ' Septic Tank: Distance from nearest well----A/O......Distance from foundation____-/1�---------material ._....)� c1d-- ------------ No. of compartments__._____-______-------Size------SX_jX3_-_-_Liquid depth__.___ 2__ _______--Capacity_______ .qw I / Disp sal Field: Distance from nearest well.._A-_-.-Distance from foundation______?�q --- to nearest lot line__ �____.___.- Number of lines--------------y_. _____Length of each line__/4fSa, fta_.V1/idth of trench___.____._ 'v_ __...____.-_- Type of filter material------{ - fcDepth of filter materi I___.______1��_____.Total length____--------_/_�_0_._____._______-____ ] Seepage Pit: Distance to nearest well---__-----------------Distance from foundation------------------- Distance to nearest lot line----------------- %-V ❑ Number of pits----------------------Lining material------------------ ---.Size: Diameter-----------------------Dept h................................ 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_____.________________________-__--___--- ❑ Distance to nearest lot line---------------------- ----------------------------------------------- G Remodeling and/or repairing (describe)--- ----------- ------------------------------•------------------------------------------------- ----------------.--------------------------------------• w ---•-•------•--------------------------------------------------------•--------•-•--------------------•---•---•----------------------------•----------------- ------------------------•--------------- ----------------------- ---------------------------------------------------------------------------------------------------------------------------------------------------•--------•---------------------------------------------------------------- -------------------------------------•----------------------------------------------------------------------------------------•---------------------------------------------------------------------------- -------------- 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 regul ' ns of t San Joaquin Local Health District. (Signed) -----/------ ------- --- ---------------------------------------------------------------(Owner and/or Contractor) --- ---------------------- ---------------------------------•-•-------------------------------------------------------•------------(Title)----- ------------------------ --------- ----------------- (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------------------------------------------------ DATE--------- � / REVIEWED BY-------------------------------------------------------------------- ---------------------------- DATE----------------- w------------------. /, BUILDING PERMIT ISSUED--------------------------------------------------------- --------------------•--------------------- DATE--------------------------- Alterations and/or recommendations------------- -----------------------------------------------------•--•-----------------------•----•----•-----------------------------------••-•----------- ---•---•---------------------------------------------------------------- --•-----------------------------------------------------•-•--•-•---------------------------------------------------------•-------------••---------- ------------------------------------------------------------------------I--------------- ------- --------------------------- ------------- ---------------------•--------•--•-------- -----------------------•--------------- ----------•-----------•----------- ------------------------------------------------------------------- ---------------------------------------------------------------------•-----------•---------------------------------- -----------•---- ---------------------------------•------------------------------------•-------- -----------------•----------------------------------------------- FINAL INSPECTION BY----------------f '` s----------- Date_- ------ _75--- ------------------------ 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 ES-9-2M I0-52 Revised W-2100