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APPLICATION FOR SANITATION PERMIT Permit No. (Complete in Duplicate) Date Issued3 ' �ApAcafion 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.___-_3.3_d -�-7 ------------------------------------------------------------------------------------ Owner's Name - ---------• - O. ^ Phone Address - �y� --••--- ------•--••-----------•-------------••-•------------•----------------------- -- --- ------- --- --------- Contractor's Name. (!_ , -- --- --•-------- --•--- Phone LFI" ----------------------------------•----- - -�_�-_.- Installation will serve: Residence A artment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other { Number of living units: __ /___ Number of'bedrooms ,.I... Number of baths _1--- Lot size Water Supply: Public system 2--161"ommunity system ❑ Private'❑"'Depth to Water Table Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe Iardpan ❑ Previous Application Made: Yes ❑ No Q-*�New Construction: YesNo ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) eptic,Tank: Distance from nearest well----- rfrom fond tion_____I __-_--__.Mate ia!__�+___e� Q/ J' l3 ---- --- No. of compartments _X..3 _-- _Liquid depth.---- o�_-- -- Ca acit OG .. p Y Disposa• Field: Distance from nearest wel!_____ l---Distan rem fo dation _ -------.Distance to nearest lot line. Q-._____ Number of fines----- _ r� ----- - --_-- Length of each line-------- ------0_-- -i Width of trench-------s9� Type of filter materially_ .___.-__. _ _De th of filter material__ -_ - 1 Total lengtfi___._..._02---------------------�--- pAA- -- a pp•. Seep Pit: Distance to nearest well-._____-7-_.-----Distance fro foun ation___-_y�f.-------Distanrfe to nearest lot Zine__ -_e----_- Number of its._______. p ----------Lining material_- -( ------. _ Size: Diameter___,,4-----------.Depth-----a��• ------------- --- 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------------------------------- -- 1771 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 , g ) - � ----- ----- ------- « and/or Contractor) By:--------------�-- --- ----- -----------• --------------------------------------------------------------------- (Title) t -------------- i Pot 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--------------------------------- BUILDING PERMIT ISSUED__________________________ ---••--------=------------------------------------------ ---------------.._ DATE------------------------------ - Alterations and/or recommendations:----------------------------------_------------ ---------------------------------------------------- -------------------•------------------------- ------ ---------------------------------------------------•--------------- ----- - =------------------- �� j -- - -•---------------- FINAL INSPECTION BY----------------[/--".-�-LI ___.�. ,_ Date__. 5 SAN,JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Street 814 North "C" Sfreet Stockton, California Lodi, California Manteca, California Tracy, California ES-9-2M �0-52 Revised W-2100