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APPLICATION FOR SANITATION PERMIT Permit NoA.3_a_ (Complete in Duplicate) Date Issued 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 Ordinance No. 549. JOB ADDRESS AND LOCATION--- ---L;----7-- ��' p --- Owner's Name---------------{ `- -- C - -------------------- ----- -------------------•-------------------- Phone ��+ ._Q_..C.. Address-------•---•------- a'.. ----------n---------------------------- ----------------------------------------------------------------------•-------------------------------------- Contractor's Name----------------k_m_ _ �-----------------•----------- - Phone---------•--------•--------- Installation will serve: Residence'®' Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ $ Number of living units: ___-_ Number of bedrooms __,—Number of baths ___ Lot size ----ZD-d- ----------------------------- Water Supply: Public-system R Community system ❑ Private ❑ Depth to Water Table -------- ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel L] Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe B� Hardpan ❑ vii� ' Previous Application Made: Yes ❑ No n, New Construction: Yes ❑ No 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 from foundation_____/dMaterial---- �_------------------- No. of compartments-----------I- ----------Size__ -3_x_-'s-------Liquid depth---------1�!-------------Capacity---- Disposal Field: Distance from nearest weli___,'�Q'`_____.Distance from foundation_ --C----- _______.Distance to nearest lot [ Number of lines------------I-___________________Length of each line----b-_c�___ _30 Width of trench_---a N_��__- _-__---._- Type of filter materialp��r•'_ ��-�___Depth of filter mater•ial______�_�__r_--.----Total length-------!_-170------------------------- ` Seepage Pit: Distance to nearest well---------------------- from foundation----------------....Distance to nearest lot line_..________._____ ❑ Number of pits----------------------Lining material-----------------------Size: Diameter------------------------Depth------------------••--------_.--- I 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------------------------------------------ Distance __ _-_________________.__---__-_-Distance to nearest lot I•ine------------------------ --------- ------------------- ------------------------------------------------------------------------- s: Remodeling and/or repairing (describe): _.1��_ t.tL_- .€ r�- -------------------------------- ----------------------------- r ----------------------•------------------------------------- ... "'. ---------------------------------•-------------------------------------•-------------------------------------------------------------------------------------------------------------------------------------- -------- 1 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. _ � I (Signed).... -�__ �� _ .__ �------------- --(Owner and/or Contractor) I By: (Title). ' (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---------- J .................. - --------=---- • --------- . ---------------- DATE------ sA -- ��- REVIEVED BY------------------------------ -- - -------------------------------------------------------------------------------- DTE------------------------ ------ --------------- BUILDING PERMIT ISSUED---------------------------------------------------------------------------------------------------- DATE---------------------------`----- ---------------------------- Alterations and/or re-commandafions:- ___-----__._______..__ ------------ ------ ----- ----------------------------------------------------------------------------------------------- ---------------------------------- -------------------•------------=-------------------- -------------------------------------------------------------------------------------------------- ---------- ------------------ ------------------------------------�?----------------------------------------------- /I�FINAL INSPECTION BY:. Date =---------- --------------------------------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Streof 300 Wes+ Oak Street' 132 Sycamore Streef 814 North "C" Streef Stockton, California Lodi, California Manteca, California Tracy, California ES-9-2M 5-51 Revised W-2100 F