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APPLICATION FOR SANITATION PERMIT Permit No. ,3----------- Is Q- I x1\ (Complete(Complete in Duplicate) Date Issued � - .�_$ Application is hereby made)+o 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 LOC it ' /ina �... ATION.. .�}----------f r , - ---- --- -------------------------------------------------------- k Owner's Name------------ ------- 1�- s _ 5-------i f---- -/: �. I__l Phone --------------- Address----------------------------------- ------------•---------------------------=------------------------------------•------------•----------•----•---• Contractors Name--------------I------------- Phone Y!o ' Installation-will serve: Residence X Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ "f g �d--X fie©-----` 's .., Number of living units: __ ___ Number of bedrooms __�Number of baths __l.-_ Lot size .___. Water Supply: Public system E4 Community system E] Private.❑ Depth to Water Table ________ ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe 2g Hardpan ❑ Previous Application Mado:11Yes ❑ No A New Construction: Yes ❑ No ❑ � TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Ta k: Distance from nearest well-----------------Distance from foundation-------------------.Material_-_---___._____.__.._________....__` ---------- No. of compartments-. - -------- -----------Size--------------------------------Liquid depth-------'____. . __._ _-Capacity �(� posal Field: f Distancefrom nearest well--%"oto Distance from foundation----JD_`__-:.Distance to nearest lofdine-___�a_ ` r ® . Number,loi lines____________�• - Length of each l ine_________la_f__ __._.Width of trench..____, 1`'�'__.____.________ Type or,lfilter material'`t1i_ ?f— - plength YP ___Depth of filter material_.:::_,�� : Total ________J fir.'___�______________ P g i See❑a e Pit: �iU�abnee:to nearest well---��`''��_C__Distance from foundation___��_r_____..Distance to nearest lot line.___��__~__ kofits------/------------- Linin material.0 Size: Diameter-- 3-- _`r '�- -_------------- - p g -_ ---------Depth__.. - Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material___.____.---___._ . -- r ❑ Size: Dia`meter------------------------------------Depth----------------------------------------------------Liquid Capacity-_- ----------------------gals i Distance from nearest well----,,-------:-----------------------------------Distance from nearest building--_-------------------------------------_. Privy- Distance.to nearest lot line----------------------------------------------------------------------- --------------•-------- ---------------------------------------------- g p `1 describe � t 4?--------- -n l� ----------------and/or (describe): -••---------- !----•--------------------------------`(---------------------------.-----------.._...--------------------------- 4 ---------------------------------•---------•----•-••--•----------------------------•---------------------------------------- ---------------------- -- -.---t --------- ------------------------------•----------------------------------------------•---•--------------------------------------------------------------------------- I hereby certify that 1 )lave prepared this application and that the work will be done in accordance with San Joaquin Counfy" ordinances, State laws, and;'rules and regulations of the San Joaquin Local Health District. tL�� � (Signed)---- �! : : _. (Owner and/or Contractor) B 1 Title (Plot plan, showing size of Iof, location of system in relation to wells, buildings, etc., can be placed on reverse side). ARTMEX USE ONLY APPLICATION ACCEPTED l$Y--- -' = -------- DATE----- ! ----------------- - REVIEWED PY------------------------11-------- ------- ----- DAT E-------------------.... BUILDING PERMIT ISSUEDI---------------------------------------------------------------------------------------------------- DATE--------- -------------------- ------------------------------ Alterations ----------- -- - - - Alterations and/or recommendations:._- --- ----•-------- ----------- --------------- ---------------- ------------------------------------------Z-------- �� I� t . r ----------------------------------------------------------------------------------- ----------------- --------- ------- - --- Ii--------------- -- ---------- --------- ----------- --------- ------ ------ ----------------------------------------------------------------------------- FINAL INSPECTION BY:--------/° -- y. 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 I0-52 Revised W-2140