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*` APPLICATION FOR SANITATION PERMIT ow' ' Permit No. -3-- --------------- (Complete in Duplicate) ` bate Issued /?/�- ��_� P`Yt-t fore Application 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 Qrdinance No. 549. 1` -707 E_ f��G FctJR4c�l ?�6 JOB ADDRESS A LOCATION�A' - -,- , -_- -_' Owner's N e---• ---------- --------- -------- ----- -- ---------------- -- ae - -- --------------------- P ----------------- h Address----- - ---- •----- Contractor's Name___ ____________________________ ' ----- - Phone -------------- Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Mot I ❑ Other Number of living units: __'(____ Number of bedrooms --&-- Number o baths ____I__ Lotsize ------------------------ Water Supply: Public system E] Community system ElPrivate Depth to Water TaXe ---- Character ft. of soil to a depth of 3 f7No t• Sand [] Gravel ❑ Sandy Loam ❑ Clay Loamy ❑ Adobe ❑ Hardpan ❑ y Previous Application Made: Yes ❑ New Construction: Yes No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if�pub.licer is availablewithin 200 feet,a Septic nk: Distance from nearesi well istanc fro foun tion_lQ_�___ ate iNo. of compartments--------------- __Size___�_YC- -----------------Liquilepth .,- Capacity--- p�� Dispose Field: Distance from nearest well .._____ - istance from foundation___ ____I___._..Distance to nearest lot lin _____________ Number of lines------- --- ---fl - ----------- --Len th of each line---__ -- + g �-Z -----Width of trench---_-- --" ""in # Type,ofgilte� materi __ . _,/ Depth of filter material_-_.__-l__ __ .__ Total length l-X-v------------•- Seepage Pit: Distance to nearesfi well ___________-_Distance from foundation.....---------------Distance to nearest lot line---- :;1 mb ❑ Nuer ofpits.._.__ ______________Lining material--__ Size: Diameter - Depth. __..______.---------------•---- 13, Cesspool: Distance..frorn,4nnearest well_________________Distance from foundation________-__._____.Lining material__.____-.______-____.___.____._ ❑ Size: Diameter------------- -------------- -------Depth-------------------------------------- -------- --Liquid CapacitY-----------•--------------gals Privy: Distance from nearest well-------------____________________________________Distance from nearest building f •. ❑ 'Distance-ternearest lot line----- ------------- ----------------- --------------•---------- Remodeling and/or repairing (describe)----------------------------------------------------------------------------------------------- F.. ---------••-----------------•---•-----------------•------------------------------ — --------------------------------------------------------•-------•--------•----••------------------------------------------•--------------------------- -------------- -------------------------------------------------• ---------------•-•------------•------------------------•---------------------------------------•- -------------------------------------- - --- noaqu I hereby certify that I have prepared this application and that the work will be done in accordance with SaJin County ordinances, State laws d regulations of the San Joaquin Local Health District. {Signed) g 9 --- -t _ -------- (Owner and/or Contractor) By:--•--------- -----•--------------••---- Title - ------- --------------------------------- -------- (Plot plan, showirij.size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY-_ __ -__----------------- DATI , --- -----------------REVIEWED BY------------------- -------------------------------------------------- . . . -------------------------------- ----- __ DATE , ----------------- - -- BUILDING PERMIT ESSUEb___.- ---- -- ----------------------------- Alterations and/or recommendations: i -------------- DATE------- •--- ------------- -- ---------------------�-----'-------- ----------- ------------- ------------------------------- ------------------------------------------------ ----------- -------------------------------------------- ------------------ - ----------------------------------------------------------- ------- ------- >� FINAL INSPECTION BY:------1,� :� �. -- Date----�. - __-_-- - �,► SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 Wes+ Oak $tree+ 132 Sycamore Street 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy. California E5---9-2M 10-92 Revised W-2100 1