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APPLICATION FOR SANITATION PERMIT Permit No. (Complete in Duplicate) 3 Date issued __ 7r_31n— Hpplica+ion 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 compliance with County Ordinance No. 549. JOB ADDRESS AND LOCATION-------- Q ------ ----------------------------------------------------------------------------- Owner's Name-----C--.--S-----------I _ -------------------------------------------- Phone------------------------------------ Address ------------------------------ --- Address----------�a.. - -----------------------------------••-•-----------------------•--••-----------------..----- ---------------------- Contractor's Name----�, -------- CL---- w� G•• Phone__ �..�.C? C G 7 Installation will serve: Residence [� Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel [] Other ❑ Number of living units: -_L__-- Number of bedrooms ---/---- Number of baths I------ Lot size ------SCS---Y-__/_0-o---------------------------- Water Supply: Public system W Community system ❑ Private ❑ Depth to Water Table -------- ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobela Hardpan ❑ Previous Application Made: Yes ❑ No 10 New Construction: Yes ® No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: 160r 0l. -c. 6 (No septic tank q�rr cesspool permitted if public sewer is availa6le within tWfeet.) U!'' Septic Tank:�P�/�1/�t9 Stan from nearest well-----------------Distance from foundation--------------------Material-----------------------.------------------------- 1� e o compartments------- - ---------------Size--------------------------------Liquid depth--------------------------Capacity----------------------- Disposal F ista e 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-----------------------Total length__-__--__----____-____-__--_---_-----_-_. Seepage Pit: Distance fnearest well_-_- pan fromfoundation------)5.......Distjpce to nearest lot line-----_ r-/--beoP Lining Diameter----- M--- -- -----Depth---------q- --------------- Cesspool: Distance from nearest well-----------------Distance from foundation.-------------------Lining material-----.._._-___._-------_-_------._-__. Q ❑ Size: Diameter---- - ----------- -------------------Depth------------------------------ --- ------ ----------Liquid Capacity----------------------------gals. Privy: Distance from nearest 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, St a aws, and rules and regulations of the San Joaquin Local Health District. (Signed)----- ---- ------------------------ -----------------------------(Owner and/or Contractor) By:..... :i �... 0�- - --- -----------------------------Title)--------C —A-1---------------------------------- (Plot plan, showing size of Jot, location of system in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY------- ----------- DATE-------- REVIEWED BY--------------------------------------------- DATE----------------- -tZ7J- -, BUILDING PERMIT ISSUED------------------------------v--------------------------------------------------------------------- DATE------------------- Alterations and/or recommendations----------------------------- ---- --- -----------------------------------------------------------------------•--- -------------------------------------------------------------------- ------------------------------------------------------------------------------ --------------------•-----------------------------------------•---- ---•----------------------------------- -------------------------------------------------------------------- ----------------------------------------------------------------------------------------------------------------- ---------------------------------------------------------------------•---- ----------------------------------•------------------------------- -------- -------- -------------------------------------------------------.---- FINAL INSPECTION BY:. --------------'-------------------------- 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 : Revised'W-2100