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APPLICATION FOR SANITATION PERMPermit 3 IT emt No.p�__�___�2_____- •, (Complete in Duplicate Date Issued Application 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 compiiance with County Ordinanc No. 549. JOB ADDRESS AND LOCATION_ - ------------------------------------------------------------ - i Owner's � Name----- --=-------- --- ---- w ----------- -------------------------------- ------------------------------ -------- one Address------------------- -------- ------------------- - ---------- ------------- Contractor's Name-- -d- 4"'° N ; - Phone Installation will serve:*'Residence Apartment House ElCommercial E] Trailer Court ❑" Motel ❑ Other ❑ Number of living-units: N ber of bedrooms r -- Number of baths _/__-_ Lot size _/_ ___--____ --- --------- I' Water Supply: Public system Community system F] Private El Depth to Water Table -------- ft. F Character of soil to a depth of 3 feet: Sand [-] Gravel E] Sandy Loam E] Clay Loam E] Clay ElAdobe ❑ Hardpan E]Previous Application Made: Yes ❑ No ❑ New Construction: Yes ❑ No ❑ TYPE OP INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic 7 Distance from nearest well, r l9Qistance r fo ndation__ _�_- � - Mater�al----- -- -------- No• of.compartments_--_ _�----___-__Size___ i uid de th_ ___capacity ,----� Disposal d: Distance from nearest well_ --d_-'1VDistance from foundation_,-------------Distance to nearest lot line-V.3 dumber of lines:_____,�'_L.S,,,_ Length of each .line------r�4- _-- ------Width of trench- ---------------------- �/ fDepth of filter material------1'_ Type of filter material - --- �----Total length__-----_- __-_____-�--------------- Seepag Distance to nearest wel!_._�-?'_ • _.Distance m foundation- ___-__.Distance to nearest lot line_`��_____ Number of pits------ g - Linin matenal_ l� ize: Diameter_- -.t : Depth____.Z.1'�_- __-_- Cesspool: Distance from nearest well_________________Distance from foundation__.____-----_____--Lining material__--------.-________________ ' ------- s ❑ Size: Diameter-------------------------------------Depth---------------------------------------------------Liquid Capacity----------------------- gals Privy: Distance from nearest well__;_ ______________ __ --__--Distance from nearest buildin ----------------------------------------- Distance to nearest lot line -r__-----___ .,--_-- ----------------- Remodeling and/or repairing tribe)=--------- -- -. _--- ----- x— s ---- --------- ---------------- } - -------------------------- - ------- it - - ------------- ------------------- - -------------- ---------- ---------------------- ------------------------------------------------------------------------------------------------- --------------------------------------------------------------------------------------------------------------------- '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, a 'd rules and regul tions of the San Joaquin Local Health District. (Signed)___ Contractor) ------ ------- - -- - ---- ---- n� � Q -- --�� --''"'-"�--� --- - - - - -- -(O ,net an r on tactor) By= �.- - = Y Tale ------ --------- - --------------------- P of 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---------�--a---.- � - � REVIEWED BY - - -------------- --------- --------------------=----------------- DATE----- T ------------------------------ ------------------------------------------------------------------------------ DATE------ BUILDING ------------------- PERMIT ISSUED--------------------------- --------- DATE-- Alterations ------------------ ---•------- --------=------- --------------------------------- terations and/or recommendations________________ -------------------------------------------------------------------------•----------------------------------------------'- ----------------------------------------------------------------------------- --------------------------------------------------------------------------- --------------------------------------------------------- ate= ------------------------------------ ---- ---------------------- ' ..� FINAL INSPECTION BY ----------------� ----------------- -- ---------------------------------------------------------------------- d .�. Date SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Street 814 North "C" Street f4.Stockton, California Lodi, California Manteca, California Tracy, California \.�S-9-2M 8-51 Revi ed-W-2100— ..