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APPLICATION FOR SANITATION PERMIT Permit No.3,11 (Complete in Duplicate) Date Issued f YDS -- Application is hereby made to the San Joaquin Loca! 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 LOCATi N_ ,2_,4_-4.3 -------- .- "----. - �"" Owner's Name----- Phone --------------- ------ ------------------------------------ Phone "�` R -------------------------------------------- --------------------------------------------- Contractor's Name----ta --- Installation -Installation will serve- Residence partment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: -1----- Number of bedrooms _- Number of baths j____ Lot size ___&S-7-A-- Water Supply: Public system A--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 @4"'gardpan ❑� Previous Application Made: Yes ❑ No 4�'New Construction: Yes ❑ No l — TYPE OF INSTALLATION AND SPECIFICATIONS: W (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tank: Distance from nearest well-----------------Distance from foundation--------------------Material __-._______---____._.___--_______-_-.._ ,.A,or/ .:� No. of compartments-- -----------------------Size--------------------------------Liquid depth-------------------------Capacity--- -- Disposal Field: Distance from nearest well-------.._------Distance from foundation------------_.......Distance to nearest lot line___________.-___- Number of lines-----------------------------------Length of each line------------------------------Width of trench--------------- ------ ----------- Type or filter material-------------------------Depth of filter material----------------------- otal length------._-_____-__-_________---- ---------- Seepage Pit: Distance to nearest well__-__Distance from foundation----- ...__. Distance to nearest lot line---- f---.... [4--, Number of pits---------/-----------Lining material___ r. ---Size: Diameter___ -`I-------Depth- ` -_-Y e 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------- = Remodeling and/or repairing (describe):------------------------------------------------------------------------------------------------------------------------ -------------------- ----------------------------------- --------------•------•-----••--------•---------••--------•---------------------------------------------- I ------------------------••-----------------------------------•-------•------------------------------------------------------------------•--•---------------------------•------------•--•-------------------------------- I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County I ordinances, State laws, and rules and regulations of the San Joaquin Local Health District. (Signed)_- ----------------------------------------_4C6q&LandContractor] By----- frtlel ,t' ` -�..-:-------------------- (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on revrseside). i FOR DEPARTMENT USE ONLY i APPLICATION ACCEPTED BY -- DATE REVIEWED BY -----�5 ------ ------ :---------------------- DAT---------------------- 1 ,BUILDING PERMIT ISSUED – ----------------------------------------- DATE -Alterations and/or recommendations---------------------------- -------------------------------- - --- ---- ----------•---------• -- --- ----- --- ----------------------•---•--•------- --------------------------- --------- -------------- ---------------------------------------- FINAL INSPECTION BY:----------- --- - -- ----------_-- - -- Date_.. --- --- -- -- _ 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 10-52 Revised W-2100