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APPLICATION FOR -ANITATION PERMIT Permit No. T3. - l {Complete in Duplicate} .Z/ Date Issued ____/____��/�� Applica+ion is hereby ma25e 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. JOB ADDRESS A LOCATION__ (____._____ - n.yt,i ------- ----- Owner's Name--------- Address C '...... ' - •--•--------------------------------- d Contractor's Name.-.-_:.�_:__�____.___ - - __ Phone._ � 3 G�s�`1� --------- Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court [] �,.M tel ❑ Other ❑ Number of living units: __i--_--.Number of bedrooms __Z_ Number of baths ---1!---- Lot size __ J�__ -_ - -- .•--------------_----------- Water Supply: Public system Community system ❑ Private ❑ Depth to Water Table Z 4rff. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe R- Hardpan ❑ Previous Application Made: Yes ❑ No 5a�-" New Construction: Yes lr No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tank: Distance.from nearest well-----------------Distance from-foundation____________________Material------ ..__.-._______._-______________--.._____:_. i No. ofcompartments---------- ---------------Size--_-------------------- --------Liquid depth--------------------------Capacity----------------------- DspDistance from nearest;well .................Distance from foundation_______-___________Distance to nearest lot line----------------- Number of lines------- ----4__.________ --Length of each line------------------------------Width of trench---------------------- Type of filter material-------------------------Depth of filter material----------.------------Total length----------------__--__------__--____------ 1 5eepa Pit: Distance to nearest well _ _________Distant froln foundation__ .___.Distance to nearest lot --- I [{ Number of pits-----k__-------------Lin ing material- ------ Size: Dia eter_------3._+----------Depth...... __f_________-_-- -- 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 _____ --.____________________________Distance to nearest lot line--------- ----------------------------------------------------- Re ---------------------------------------------------Re eling a d/ r r airi de crib C---- ---------- _--.-. -- _-- _Iva s 1 �f --------------- -------------------------- -------------------------- --------- ------ ---- ------------------------------------------- a ____ ________________________________________________________________________________________________________________________________________________________________________________________________________________________ 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. (Signed)........ti-- - -------- - -----``--Y"�-'---------------------------------------- --------------• ----------(Owner and/or Contractor) BY: 1- `' -'^+s----------------------- ----------------•--•----------------(Title f (Plot plan, showing size of lot, ocation of system in relation to wells, buildings, etc., can be placed on reverse ssUee). FOR DEPARTMENT USE ONLY I APPLICATION ACCEPTED BY__Q-------------------------------------------------- --_---------_. DATE----,%----------- REVIEWEDBY----------------------------------------- -,•------------------------------------------------------------------------------ DATE---- ------•------------------ BUILDING PERMIT ISSUED------------------------------------- •----- ----- - ------•---- ---------- DATE,-------�----•------------------------ ,r -- ----- �� - Alteratibns and/or reco endat' ns: -A=,Y _.a -j 4 - - 1 --------------- . 1__j .. 3---._1-- �------------ ---------- i. 1� ----------------- - --- ------- -- ----------------- -_--- ------------------------ --- --------------------------------------------------------FINAL INSPECT111ON BY:---------- --- ----- ---- Date------ N JOAQUI 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 ; ' Revised W-2100