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APPLICATION FOR SANITATION PERMIT Permit No.C;�3 d-- (Complete in Duplicate) /Q Date Issued -_-- -35 �. Application is hereby made to the San Joaquin Local Health Mstrict 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 LOCATION___._/S(1SS__(�t/: r �-- ----------- ----------------------------------------------------------- Owner's Name--------------t n:_*__ M- '�---•----------- -- --------------- -- ----------------------- ----- - -------------- ------------- Phone-------------- ------------------ Address----------------- _i/L ------------------------------------------------------------------ - Contractor's Name--------------------------•--/f--------------- ------------------------ Phone Installation will serve: Residence g Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: -------- Nu ber of bedrooms __3-- Number of baths 0__ Lot size _________-5 --- --------------------------------------- Water Supply: Public system Community system '❑ Private ❑ Depth to W Table -------- ft. Character of soil to a depth of 3 feet: Sand ❑ _Gravel [-] Sandy Loam lay Loam El Clay ❑ Adobe E] Hardpan [3Previous Application Made: Yes E] No --Gravel Construction: YesZIIN15"M TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tank: Distance from nearest wefI_A_14M„Distance from foundation__!_.}-----------Material--- -c No. of compartments----'�----------Size „ --- ---Liquid depth__- Capacity ri l - 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 of filter material___-�- --Depth of filter material_____ length- Qistance to nearest lot line_______-__ ��1� _---Total _____�-�--,- Seepage Pit: Distance to nearest well 6_0 from faundaiion___________________. De th ------ ❑ Number of pits______________________Lining material_-_____._____________..Size: Diameter------------------------ p Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material------------------------------------- El Size: Diameter--------------------------------------Depth------------------ -------------- ------------------Liquid Capacity---------------- gals, �, -------- -- Privy: Distance from-nearesf-well------------------------------------------------ Distance from nearest building-------------------- --------------------------------- -----------. ❑ Distance to nearest lot line Remodeling and/or repairing (describe)___________________________ -------------------------------------------------------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. ; (Si ned) -- r j , s� , . By: - ��-- ------- -,!--------------------------------- ----------(Owner and/or Contractor) ------ --•------------------------------------------------- Title _ _____ __ - ---------------------------------------------------- -- -- - (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY a . -l APPLICATION ACCEPTED BY -------- la z. DATE REVIEWED BY ----------- -- DATE-----------p BUILDING PERMIT ISSUED--------------------------------------------------------------- ---------------- DATE Alterations and/or reeommendations:_____________________ _ ---------------------------------------------------------•------ -------------------------------------------------------------- ------------------------ ------•--------------------------------------------------------------------------------------------------------------------------------------------•-------------------------------------------------------- --------------- ----------------- -------------------------------- ---------------------------- v� FINAL INSPECTION BY:-------------- ----------- -- --- -- - Qate 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 8-51 Revised W-2100 F