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ti {� `J APPLICATION FOR SANITATION PERMIT Permit No. _3 ...... (Complete in Duplicate) -/ D rf `t`z[a pate Issued 02 Applica�ion as hereby made to the Son Joaquin Local Health District for a permit t r�E ,01;'JW- wor ergm This application is made in compliance with County Ordinance No. S49. '* v �� SSc E. tG` �i4 2•b ' rl?.I1i;- JOB ADDRESS AND C TION -------- � !- �J O -•---------- ----- . �!Owner's Name -'- - --------------------- ---- --------------------- --- ------------------------ hone__.---- OL e Address ........... • _.. _ -- -- ..•. Contractor's Name---------------------------------------------------------------------------------------------------------------------------------------------- Phone-----------•----------------------- Installation will serve: Residence`�partment House [j Commercial ❑ Trailer Court E] )Motel L] Other F]Number of living units: ___-/- Number of bedrooms _a-- Number of baths 1____ Lot size __ // - "«"r`_________________ Water Supply: Public system ❑ Community system ❑ Private [§►Trpth ater Table _1------ ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel E] Sandy Loam Clay Loam 0 Clay p Adobe ❑ Hardpan ❑ Previous Application Made: Yes ❑ No [ROOONew Construction: Yes ❑ No 2� 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 _.----.Distance fr m foundation-__�_A�_+_____.Material_---0210__.______ 11101111___ _ Z No. of compartments_.___.'`�.____-__._.____Siz�X__!_)—C .---Liquid depth_�f r_..___-___ Capacity__ 4a 1 - �-- -------- Disposal d Disposal Field: Distance from nearest well_�}�_—.._.._____Distance from foundation___�a�_____.___.__.Distance to nearest lot IineV7___._._. Number of lines------ ----------- ---- ---------Length of each line__�_2—.�- -:-,_.___-----Width of trenc -------Total length--------' .'Gay1----------------�-1 Type of filter material_- --------Depth of filter material-4______._ , Seepage Pit: Distance to nearest well----------------------Distance from foundation--------------------Distance to nearest lot line__________.___.__ ❑ -Number of pits----------------------Lining material---------------------.Size: Diameter-----------------------Depth---------------__-.-------------- °Rl Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material_._._.______________.__--__--________. ❑ Size: Diameter--------------------------------------Depth-------------- ----••--------- ---------------------Liquid Capacity- ------------- ------------gals. Privy: Distance from nearest well.------------------------------------------------Distance from nearest building------------------------------------------ El Distance to nearest lot line---------------------------------------------------------------------------------------------------------------------------------------------- Remodeling and/or repairing (describe):--------------------------------------------- ------•--•--•-----------------•----------------....----------------------•----------------00••00.0000-0000-- - � ---------------------------------- ---------------------------------------•-•----------------------------------------------------------------- -----------------•------••------------------------•---------------------•----•------------------------------------ - ------------------------------------------0000-- ------------------------------------------------------------------------------•--•-••--•---------------------------------•------•---------------------•---••--0000---0000-- I hereby certify that I have prepared this application and that the work will be done in accordance with San JoaquinCounty ordinances, State laws, and rubies and regulations of the San Joaquin Local Health District. "" _______________________Owner and/or Contractor) ( (Signed)00 000-•--••-'-•------�-��--�-0000-- By:--------------------------------------------------------__---------------------------------------------------------------------(rtle)--------------------------------------------------------------- (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 APPLICATION ACCEPTED BY---.--------------- -- ----------------- -----------•---••----------------------- DATE-- --• - - - REVIEWED BY----------------------------------------- ------ DATE = f BUILDING PERMIT ISSUED---------------- - ----------- -----•-------------------------------------• DATE--- -------------- -------------------- - Alterationsand/or recommendations:--------------------------------------------------------------------------.---------------------••----------.-------------•------------------------•---------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ----••-------------------------------•----------....--..-----------•------------------------------------------------......._--------------------------------------------------------- --------------------------------------- ------------------ ------------------------------------------------------- ----------------------------------- ----------------------------- ----------------------------------------------------------------. -------- FINAL INSPECTION BY:---_---- .0111-- 1101 ��-- lam`? Date.- 7-- 5 f--'L 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