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" APPLICATION FOR SANITATION PERMIT 1&Permit No. 3 / ` (Complate in Duplicate) y / Date Issued -----/- Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described. I This application is made in compliance with County Ordinance No. 549. JOB ADDRESS AND LOCATION------------ =e�-�r' L�//� � CO- ---------------------------------------------------- I � OwnersName--------------------- �^21CY------ f ... �_ � ---------------------. - -- Phone'---------------------- -------- Address3={ -'--------------------------------------•--- •-------------------------------------------------------------------------------------- ----------------------- Contractor's Name--------•---- '-------- I----------------------- Phone----•------------------------------ a + f Installation will serve: Residence A Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: /____ Number of bedrooms F.:_ Number of baths _ ___ Lot size ----------------- Water!Supply: __.___________Water!Supply: Public system ❑ Community system '❑ .. Private Depth to Water Table -------- ft. Character of soil to a depth of 3 fee+: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe ❑ Hardpan ❑ Previous Application Made: Yes ❑. No ❑ New Construction: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) i Septic Tank: Distance from nearest well----D-------Distance prom end n------ __ ..._....Material____ _ _� j No. of compartments-- __ - .___0/depth'_, --��--------------Capacity----�� Disposal Field: Distance from nearest well...... ---__-Distance from foundation___ ��___ Distance to nearest lot line-----�_-------- 3 Number of lines____________`___ Length of each line________ ./_�_._�_�____-Width of trench.____.- ! �� .. [� Type of filter material__S� %f -_Depth of filter material .__ - Total length_-__-___..._/ �J --------------- Distance from foundation____________.___.Distance to nearest lot line____._.___._____{ Seepage Pit: Distance to nearest well_______________ - Number of pits----------------------Lining material-----------------------Size: Diameter.-------------.--------Depth--------------------------------. , Cesspool: Distance from nearest well-----------------Distance from foundation......__._._------Lining material-----------------------------.-___._ ❑ Size: Diameter--------------------------------------Deoth---------------------------•--------------- ----Liquid Capacity----------------------------gals. Privy: Distance from nearest well ___________________________________-------------Distance from nearest building-----.-------_---- ._-.--------.____--- ❑ Distance to nearest lot line--------_-------------------------------------------------------------- r Remodelingand/or- repairing (describe):--------------------------------------------------------------------------------------- -----------------------------------------•----------------.--•---- I. ----------------•-•------------------------------••-------------••---------•-----------------------------------------------------------•------------------------------------------------- t � .,r k -----------------•---------_.------------------..-----•--------------------------------------------------_-•---------------------- -------------------------r------------------------------------ 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, State laws, and rules and regulations of the San Joaquin Local Health District. j e : . ctor ISi (Signed)-. i {Owner and/or Contra By .------------------- -------------------------------------------------------------------------------------------------------(Title]------------------------------------------- - ---------------- ` (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPAR ENT USE ONLY Ile ' APPLICATION ACCEPTED BY------- -------- - A c --f--------------------------- ---------- DATE-----------,--- ,. - ., rREVIEWED BY --------------------- DATE - BUILDINGPERMIT ISSUED_'----------- -------•----------------------------------------- t--------- DATE---------------- -------------------------------------------- Alterations •------- ---- Alterations and/or recommendati ns:___._-" =: ----------------- ---------------- ----- VP j. fl._13_ ^ '�r.Gr -----•----•-- ---- ` - -- ' =- _ -------------- y� -------------- - i 4 .: -` Ya:. ---------- �• Cry-------------- - -//---r�--- --- FINAL INSPECTION BY---------------- '.. ------- Date ---------- ------------- SAN JOAQUIN LOCAL HEALTH DIS RIC # 130 South American Stet 300 West Oak Street 132 Sycamore Street 814 North "C" Street ` Stockton, Cali ornia_ Lodi, California Manteca, California • Tracy, California # �� y _. `6 I�`d �lr1> �1 a�Tu'�rC 5. ?f �Y1fIL t'R '�` i''' k ES-9-2M 0-52 Revised W-2100 1