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, I � APPLICATION FOR SANITATION PERMIT Permit No. _- ----�.--.... d. (Complete in Duplicate) 3-1 51 Date Issued -----pp --- ! ----. Application is hereby made to the.San Joaquin Local Health District for a permit to construct and install the work herein e ibed. - This application is made in compliance with County Ordinance No. 549, // -----------------------------------------------------------•------------------------ JOB ADDRESS AND LOCATION____-_-1 - -- r -- ----------------- Owner's Name ------- ----------- Phone 'Y= ` Address----- -�-Z/J'- '�' " " '!. '----------------------------------------------------------------------------------- -------•••-•-----------------•-------------•- Phone__4-061-21 /2 Contractor's Name--I----- ----•-'�- --- ��--------"� - --- -------------------------------------- ------------------------- •---------------- Installation will serve: Residence '® Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: _�--- Number of bedrooms __3-_ Number of baths __/-_ Lot size ----------------- Water Supply: Public system D? Community system ❑ Private ❑ Depth to Water Table ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe Hardpan ❑ Previous Application Made: Yes ❑ No 'Z New Construction: Yes;ff No ❑ �.. TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sayer is available within 200 feet.) Distance from foundation__-_,/A`.__-_ Materiaf_________________________________--------------- Septic _ Tank: Distance from nearest welL�--._ • 640- 4 No. of compartments-------- --------------Size a'��"__ q4X_�0----Liquid depth---- ��L-----------Capacity____.9 i #} �d(3 �_'� _____.__Distance to nearest lot line__'rr {� Disposal Field: Distance from nearest well_..._ Distance from foundation_:__ `l Number of lines-Al 1_____- ------------- -----Length of each line--------7.,S _ ---------Width of french--- -----------:----------- q Type of filter material �_./LO _____Depth of filter material_-.--.�-�_______._Total length_____,73�________________________ H 30 ' line Seepage Pit: Distance to nearest well)14_ _________Distance ation_---_ - Distance to nearest lot ____..._____---_ ® Number of pits.-- 1____------Lining mater- I___ ___ _________ ze:+Diameter------ +--' __-----Depth_____ `��-- - w ------------- Cesspool: Distance from nearest well-----------------Distance from foundation_-__..___.---___—.Lining material--------------------.---------__.____. O ❑ Size: Diameter--------------------------------------Depth-------------------------------�---- --------=-----Liquid Capacity gals. -1 Privy: Distance from nearest well-------------------------------------------=----Distance from nearest buiiding----------------------------------------- I] Distance to nearest lot line----------------------------- ------------------------------------------------ --------------------------------------- ---------------------- Remodeling and/or repairing {descrihe)------------------------------------------------------------------------------------------------------------------------------------------------------- f 1 `--•------•-------•------------------------------------------------------- --------------------------••----------------------------------- 1 -----------------------------------------------------•-------------- --------- -------------------------- -•--------------------------------------- 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.' { Fl ( ner and/orContractor) ---------- -----------------------=--------------------- '______ __. ____� ------ (Signed)----- ..r -rA - --------------------------------(Title)------- - (Plot pian, showing siie of lot, locatiof system in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY 1 APPLICATION ACCEPTED BY--------- ------------------------------------------}-- DATE l� r' � +► ------------- DATE---------------------------t -------------------------------- - REVIEWEDBY---------------------------------------------------- --- --- -�'--------------- - BUILDING PERMIT ISSUED------------------------------------------- DATE Alterationsand/or recommendations:------------------------ --- ------------------ -------------------••----------•------------------•--------•--•--------------------------------------------- -------•------• -----------------------------------••-------------------------------- --------------------------------- 1 ---------------------------------------- ----------------------------------------------------------------- -----• 1 i - - --------------- ------------------------------------------- ---- ------------------------------------ + FINAL INSPECTION BY: Date--- ------ - •-------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 306 West Oak Street 132 Sycamore Street 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California ES-9-2M 10-52 Revised W-21x0