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i • �t APPLICATION POR -SANITATION PERMIT Permit No. •3 ,� - (Complete in Duplicate) - t Date Issued _ _____-_ + cS . ------•-/ Applica4ion is here0y made 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.J14 i 1 JOB ADDRESS AND OC TION_ ._____ Q 4---- I �. - .......... ----- ----------------------------•------- Owner's Name----- ---•- -------------------- --- -- ----- —�-. ...�;.:;,4 F:-: � ::: � ------ -------------------- Phone S Address_______..__5._� � " - ---- -------------------------- Contractor's Name_________ ___ _ _____- jr " - -------=----------=--------------- --•--- Phone Installation"will serve: Residence : -__-- o Z F Aparfinent Hose ❑ Commer_cial ❑ Trailer Court p Motel ❑ Other ❑ Number of living units: ___�___ Numberof bedrooms _ a� V l -_ Numbaer of baths _1--- Lo;size -_------ Yee Water Supply: Public(system I -- --•------------ ----- Community system ❑ Private,❑ Depth to Water Tablef}- ` Character of soil to a depth of 3 feet: Sand , d i ( ❑ Gravel [] Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe Previous Application Made: Yes ❑ No Q' Hardpan E]� L"1 New Construction; Yes No ❑ � � TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic fan k.or cesspool permitted if public sewer is available within 200 feet.) Ta.k: Distance from nearest well-_____-___\____Distance from•foundation__? _______E____.Material________-___.__--------•---•--------- ------ o. of compartmeIs Size ---- -_---Liquid depth_-------- - Ca aci3 e ! P ty-----------------------4pti posa field: Distance from nearesf-well�� -2_"Distance from foundation----- _ -_._._.Distance to nearest lot line___.__3 Number of fines_-___S_ }__ 4 +-t k k - -- -------- Length./of each line-------P�d_'____----- Width of french______ ,T/ Type or filter material_.__S(_-- _ - -' —� �• __Depth of filter iiaterfal ._ �_ 1�._ _ _ Total length �� -------- ----------------------------- Seep ac� Pit: Distance to nearest.well�- _" Distance from fo ndation_.__ v�,__...Distance to nearest lot line__. _""".. 0 Number of pits.._ __""Lining material��---Size: Diameter__-___��_�__ .2S ' r ---.Depth-- Cesspool: Distance from nearest well------------------Distance from foundation--------------------Lining material__-.____._ Size: Diameter =------------- ----------Depth-------------------------------------- .-- ---- Liquid Capacity,--.-•----------------------------- -------------------- gals. V1 Privy:: Distance from nearest well______-----__________ � --------------____.__-_Distance from nearest building V Distance to nearest`Jot line:=.__�______________�� • ----------------- Remodeling and/or repairing (describe):______________________ ----- -----------------------••--••---------••--------------------•---- ----••-------------•--------"--••--••----•--•---------------------- •------------------------------- i# ,� -------------------------------------- --------------- -------- S ------------------------------------- =--------•----'-.--- -'-----------------------------------------------•---------•-----•--"-----------•-----------------•-------------------------------•---•---•-----s---------- I hereby certify that I have prepared this application and fhaf 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. • l: (Signed), ------------ (O er and/or Contractor By:-------------- — - = - (Tale} (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can belace p d an reverse side). FOR DEPARTMENT USE ONLY t APPLICATION ACCEPTED BY------------ ----------------------------------t - -------------------------------- DATE -------• - REVIEWED BY ----------------------- ----------- ---- - - - � _..r_��---r'=--�--- - ----- DATE-------------------------------- ...........................T ------ BUILDING PERMIT ISSUED__------=--•------"""-•- -------••---------•------""""-- - ------------•-- DATE ---------------------- Aterations and/or recommendations_______________ _________________ I _____________________________________________________ kJ ____________________ ____________________-_ ------------- --------------- -- F FINAL INSPECTIONBY:- •,- ------ _ ro 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-4-2M Revised W-2100