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APPLICATION FOR SANITATION PERMIT Permit No. _ --3.---.U-- el (Complete in Duplicate) Date Issued i Applica+ion 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. 149 J08 ADDRESS AND LOC ION-_----- -------------- ---- - Phone Owner s Name-.___ _ -------------------------- n I Address-------- - �„ - I ! -----•-------- --- Phone2 r� Contractor's Name-- i!- --- - -------------------------------------------------------- ❑ Instal la+ion will serve: Residence partment House ❑ Commercial ❑ Trailer Court Motel ❑ Other ❑ Number of living unit'I: _/-__,Number of bedrooms _ umber of baths /---- Lot size ___r __ II Depth to Water Table Water Supply: Public system ommunity system ❑ Private ❑ Character of soil to a depth of 3 fee+: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam [IClay ❑ Adob ardpan ❑ I P I. Previous Application Made:!'Yes ❑ No @4--1Te_w Construction: Yes ❑ No E - TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) i; - -- - Distance ffoundation---�11..---r--material,--- --------- ---- ---------- -------------• Septic Tank: Distance from nearest welL - from - -,�,�^ -X3.---Liquid depth.-- - -- No. of compartments----- ----- --------- -- •-- -- { ------------Capacity - O ----Size_-- Disposal Field: Distance from nearest well_ _-. Distance from foundation-_ �__- ----Distance to nearest lot Iine__�...___. Number of lines-------,/-----j- ------------Length of each line-----. -------- Width of trench-----± `f___.-.______-----.. De th of filter material_-----J-e--------Total length____a--�__=__._--_ ---------- Type of, filter material------------------------ P / Seepage Pit: Distance to nearest well+'?--�+�----Distance f om foundation___ ___ _� Distance to nearest 10# line----- a Number of pits------I-------_----Lining material__ ---- Size: Diameter------ 3----------Depth---- '--------------- b Cesspool: Distance from nearest well_______________Distance from foundation__.--------.......Lining materia!_____,,.__.__.__._._______--____-- Li uid Capacity gals. j ❑ -------------------------- -----------Depth ---------------------------- ------ ------------ q p Y--------••------------ 1 Distance rom nearesf waif. lame er s �. . .. =` == Distance from nearest building----- -------------------------------- Privy: - ------ --------- -- 4 ❑ Distance to nearest lot line----- --- ----- ---- -- ... -----------------•. -----•----•-----•------•-------- Remodeling and/or repairing (describe---------------- -•----------•---------------------------------------------:--------•----- ------------- ------------•--------- -•------- ----------------- = f i I hereby certify that I have prepared +his application and that the work will be done in accordance with San Joaquin County l ordinances, Sta L S. an" rules and regulations of the San Joaquin Local Health District. - -- ------------------------- ----------------------------------(Owner and/or Contractor) (Signed)..- sY� ----- ------ - ------- -- (Plot plan, showing size of;lot, location{of system in relation +o wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY--- . -- -- ---- ---------- -----•---------------- .._.. ------ DATE---- ------------------- DATE--------- ------ - ------ REVIEWEDBY----------------- -;--------------------- ------- --- -------- TE 0 BUILDING PERMIT ISSUED---------- ---- ------- -------------------------- ----------------- DA ------- --- •�. --. ---------1z , Alterations and/or recommendations:.------------- --- - - -- -- ---------------------------------------------•--------------- }- _ --------- ------------------------------ -r ----- - A- �,,� , ..._.... ------- ---- - ---- -- --- -- ----- •- - ... - -----...... Date f . FINAL SPECTION SY----------- ------ ---• _ SAN JOAQUIN LOCAL HEALTH DISTRICT 30D West Oak Street I32 Sycamore Street $14 North "C" Street 130 South American Street Trac California Stockton, California Lodi, California Manteca, California Y. ES--9-2M 145446 nTwona ;ia-sa I