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APPLICATION EOR SANITATION PERMIT Permit No. ../._..__ (Complete in Duplicate) 3/ /3 Date Issued .._._ _ .��- Application is hereby made to the San Joaquin Local Health District for a permit to constru . and install the work herein described. This application is made in compliance with County Orli ance'No. 549. s • JOB ADDRESS AND LOCAT O Xo' ----- __ a .,-- --------- -- ------------------------ -.1-1 -- - Owner's Name ^- -- ----- --- " ------ AddreAddress ss----X -------- �-------- -----0---- --- -- ------- r -- -•• - Contractor's Name------- =1 ------------'------------------- Installation -----------------Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ .Moofel ❑ Other ❑ Number of living units: --.1____ Number of bedrooms_ Number of baths _��Lot size ____./_ ----- --� _______________________ Water Supply: Public system Community system ❑ Private ❑ Depth to Water TableOV ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe ' Hardpan ❑ Previous Application Made: Yes ❑ No New Construction: Yes 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----------------- from foundation--------------------Material_____--________--------_-__________-____-_--_. ❑ No. of compartments------------------------Size--------------------------------Liquid depth--------------------------Capacity----------------------- Disposal Field: Distance from nearest we€l-----------------Distance from foundation-------------------.Distance to nearest lot line_____--______-__ .❑ Number of lines---- ------Length of each line--------------- ---------.Width of trench----------------------------------- Type of filter material_______------------------Depth of filter material-----------------------Total length_._-_________---__-_____________._________ Seepage Pit: Distance to nearest well------ --- --------Distance from foundation-------.------------Distance to nearest lot line__-_______.___._- �, ❑ Number of pits--------------- Lining material-----------------------Size: Diameter-----------------------Dept h.------------------------------- Cesspool: Distance from nearest well--/----__Distance from oundation-__�d�__Lining material__��<_ __ r Size: Diameter------ ------------------------Depth---- - --------------------------------------Liquid Capacity------r1/a-------------gals. ______Distance from nearest building _________________ Privy: Distance from nearest well------------------ ----------------------- g------------------- ---_ ❑ Distance to nearest lot line---------- --------------•----- ------------------------------------- ---- ---------------- ---- ------------------ Remodeling and/or repairing`F{ 0 scri ):_____ __ --_. Lr- f - ----..... � -- - - -• _ -- -- ------- -------------I ------------=---------- ------------------------- -------------------- -------------------------- --------- ---------- ------ - - I hereby certify that I h e prepare this application an that fl a work will be done in accordance with San Joaquin County ordinances, laws n ules a r ulations of a Sa oaquiAocal Health District. I (Signed]-.- _-- - --- ---------- -- --(Own /or.Cantractor) r! Title ______ $ - --------------------------------------- ----(Title) (Plot plan, showinc�size� t, ocatio of system in relation to wells, buildings, etc., can be placed on re . Yse i = FOR DEPARTMENT USE ONLY APPLICATIONACCEPTED BY--- --------------------- --- ----- ---------------------------------------------------'------- DATE---------�j�--------- --------------------------------- REVIEWEDBY-------- ------------------------ ---------- ------ =------ --------------- -------------------------•-------------------- DATE------- -- -----eP ----------------------------------- ' .BUILDING PERMIT ISSUED----------------------------•-- --- DATE -- --� Alterations and/or recommendations:--------------------------- -- ------ ------- i�� - - -, --- -------------- ------ --- - ---A -- - +' --- am - - - --•- ------------ ----------- -----L--------=L__ -- -- ------- .------ --- -- ----- • --------- -- -- --------*----------- --- - -_-.--- -- -- , -• --------___ _______-- i - -------------I AL INSPECTION BYi------- - -- �-----r'"----- 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