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f � � APPLICATION FOR SANITATION PERMIT Permit No.3___ ___________ � ��- (Complete in Duplicate) / 3 Date Issued - - ---- -------- pli n a int t work herein described. Application is hereby made to the San Joaquin Local Health Dist for a permit to construct and install he This application is made in compliance with County Ordinance No. 549. / JOB ADDRESS AND LOCATION---------l "_ __ __ __ 9 �-------- � ------------------------------------------------- Owner`s Name-------------•-------------•-------••--- _ 1. f1 +f �`'I� ...----------------------------------- ----- -- Phone--�= . Address--------------------•--•--.....---------------------- � i�7 . /4'�-------------------------------------------------------------------------------------------- Contractor's Name--------------------- � � Phone 9=_� D ------- '--- Installation will serve: Residence N' Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: _1_____ Number of bedrooms -_Number of baths _/_____ Lot size ____---O-------- __I_ --- ----------- Water Supply: Public system X Community system ❑ Private ❑ Depth to Water Table ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe,K Hardpan ❑ Previous Application Made: Yes ❑ No)j� New Construction: Yes ❑ No ❑2641P -a: --- TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) fD,, vTDistance from nearest well-_-_'__-_______Distance from foundation___________________.Materiai_____.-________________._._-___.--_------__� No. of compartments--------------------------Size--------------------------------Liquid depth--------------------------Capacity------ -------------posal Field: Distance from nearest well_4_D_PIQ_---Distance from foundation_1Q__...........Distance to nearest lot line__________ dumber of lines________I__-------_--------------Length of each line----(5gp_-___----------Width of trench._ 4r_-_---_______-_____.____ Type of filter material___ �-__l s ..___Depth of filter material____._1. ��-------Total length___.��-'___________________________ Seepage Pit: Distance to nearest well______..'___._"'__'_Distance from foundation 171 to nearest lot line_________________ ❑ Number of pits-------- -------------Lining-material----------------------.Size: Diameter-----------------------.Depth--------------------------------- Cesspool: Distance from nearest well_-__s`______._-_Distance from foundation-------------------.Lining material------------------------------ ❑ Size: Diameter---------------------- -- Depth------t---------------------- -------- Liquid Capacity ga Privy: F Distance from nearest well---=--------------------------------------------Distance from nearest building_ -:-------------------------------------. ❑ Distance to nearest lot line---i----------------------------------I----- ------------------------ ----------------------------------------------•-- -------------- Remodelingand/or repairing (describe):--------- ----- -----------------------------------------~------------------------------------- -----------------------------••------------------------ ( l t ----------------•----•-------------------------------------------------------...------------------------------------------------------------------------------•------•---------- -------------------------------- ------------------- ---------------------------------------------------------•---------------------------------------•---------------------•------------ -------------------••-----------------------•---------------- I hereby c�t'ify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State la s, and rides an`ENegulations of the San1sJ aquin Local Health District. {Signed] - ---� /on -;------- or Contractor] i ------------gY= -- ------ (Title]_rte_ a9 _ (Plot plan, showing size of lot, location of system in relwells, buildi gs, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY --------•------------------------------------ DATE-----------•-- --------------------- APPLICATION ACCEPTED BY______________________�-,--------�- 2 s REVIEWEDBY----------------------------------------------- - -------------------------------------- DATE--------------- - —-- -------------------------- � BUILDINGPERMIT ISSUED-------------------------------------------------------------•---------------------------------------- DATE.------------------------------------------------------------ Alterationsand/or recommendations:---------------------------------------- --- - ---------••------------------------•-------------------------------------------------------------------------- ------------------•---------------------------------•---------------------------------------------------------------------....----------------------------------------------------------------------------------------------- -----•----------------------------------------------------------------------------•----•-----------------------------------•---------------------------------------•-------------------------------------------------------- k FINAL INSPECTION BY%.---------- � � Date-- --------------- ----- - ------------------------------- Ir � -I 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 10-52 Revised W-2100