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*�`N APPLICATION FOR SANITATION PERMIT Permit No. -- c.e7 (Complete in Duplicate) /5 S� Date Issued O t_c L,kL �4 OF ' 19'7-2-30—3.3 Applica4ion 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 OrdindInce No. 549. 1J JOB ADDRESS AND' OC TION '------ --.___�_____-- _�_- -`--- (Z -;� w --- Owner's Name= ----- ' -----------+-- ------------ ..---------�----------------------------------------------------- Phone----------_----------------------- Address ----_---------••------------ F Address---------------`��--'�------ ..------------------ •---------- ------------------ •-------------------------------------•------------------------------------- Contractor's Name ---- ------------------ ---- ' ------------------------------------------------------------- Phone------------ ------------•----- Installation will serve: Residence (Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other Number of living units: J____ Number of bedrooms _t3l Number of baths J___ Lot size21T________________________ Water Supply: Public system ZCommunity system ❑ Private ❑ Depth to Water Table -------- ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam Clay Loam [IClay ❑ Adobe El Hardpan E]Previous Application Made: Yes ❑ No 91 New Construction: Yes o ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public seer)is available within 200 feet.)/Arl1 Septic ank: Distance from nearest well---------Disra e fromp fn�und tion 4f Maltgi9---Y± ------------ ; 011 No. of compartments---------- + .--tom------ -,S,i�ze -----------x�-Liquid 4�depth-f----T-------------Capacity--- - /----- Dispos Field: Distance from nearest 14� 1 0 n::_Distance from found tion ��7t1 'n'_ ice to nearest lot lines__.~__ Number of lines___________ - _.____ Length of each lineth of french----------/ __________ 4 Type of filter materielEmpth of filter matera _ 1Total length_______-____________ ___, ,,,,,�-� See ps Pit: Distance to nearest w li____�(!_ _ Sistanc rom f n tion--.--- _ .___.D sOf t to nearest lot { ne_ _ ----------- Number _ } } �� Q Number of pits---------- ---------Lining material_-._------------------ ize: Diameter----- Depth.......... 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 lotline---------------------------------------------- ------------------------------------------------------------------------------------------------ Remodeling and/or repairing (describe):--------------------- -----• -------------------••----•------------------------------------- --•--••...................••---------- ---------------•------------------------------------------------------•----------•--•---------------------------- --------------------------------------------•---•------------------- ---------------------••------------- -•----------------•-••------••----------------------------------------------------- ..................I--------------------- t - -------------------------------------------••------------------------------------•---•----••-------•---------••--------------------•--•-------•-------------------•------------------------------------------•---------------- I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, Stafe la s, and rules and.regulations of the San Joaquin Local Health District. e (Sig ned).-j-- -•-- 4L14-i = r ^^. ----- -----------------------------------------------------------------(Owner and/or Contractor) By:-------------------------------------------------------------------------------------------------------------------------------------(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_ DAT��-__ ------ ------ ----------------------------------------------- - ---------------- -------------- -------------- REVIEWEDBY---------------------------- - ---�------------------------------------------------------------------------------- DATE_- -•------------------------------- BUILDING PERMIT ISSUED---------- ? - DATE Alterations and/or recommendations:__--___.__- __. T xf'__ _____-_ ............... -____________._.________------_.------------------- ______________________________________________________________________________________________________________________________________________________________________________________...______.--_-____--.-_._______________- ________________________________________ ----_------------_---------------------------------------------------------------------------------- FINAL INSPECTION BY:.__-____..____.__.____-. 2 �v� ------------- ZDate--- ---- ---- --�- ----- ------------------------------------------•---- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 Wast Oak Street 132 Sycamore Street 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California ES-9---2M Revised W-2100