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APPLICATION FOR SANITATION PERMIT Permit No. (Complete in Duplicate) 3 - Date Issued Applica{ion is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described. E This application is made in compliance_ ompliance wiit�t77h CCjounty Ordinance No. 549, i JOB ADDRESS A LOCATION-.._ �r�``_ -u-� _.U-__--____ Owner's Name_____--______ - Phone --------------- ------ 1 Address------- .. i - -------- Contractar's Name--- ------G:z�------- ------- ---------------------------------- Phone . :P _ -f Installation will serve: Residence Ej-_-Apartment House ❑ Commercial ,❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: /----- Number of bedrooms _3--_ Number of baths f'__ Lot size ------- Wafer -----Wafer Supply: Public system ❑ Community system O -Private ❑ Depth to Water Table _ 6 ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe(Hardpan ❑ I Previous Application Made: Yes ❑ No�.New Construction: Yes P�J_No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tank: Distance from--nearesr well_.->L {---Distance'from foundation___19-----------Material_.[r�-e_ Q No. of compartments_. �j_ Size_s,fj _ --6--_--Liquid de th.. ` �ip. -------__._Capacity___a/ .2 Disposal-Field: Distance from nearest weil...14Z".___Distance from4oundaf on�-��_-----.Distance to nearest lot line_��__- Number or lines___.___.-__�..__ Length of each Width of trench- fr 9 Type of filter materiaL_/A___. Depth of filter material-_/95------------Total length-------- ------__--------- Seepage Pit: Distance to nearest well..'4 off.. ---Distance from foundation------� .______.Distanc P nearest lot line____ 6_�___ ❑ Number of pits.----/___------_____Lining mate ria DiameterDepth `_f`----_-- (NI Cesspool: Distance from nearest well_________________Distance from foundation____________.__.___.Linin Lining material------------------------------------- ❑ Size: Diameter----------------- -------------------Depth--------- ------------------------- - Liquid Capacity gals. Privy: Distance from nearest well.............. --------------------- .. ...____--.._Distance from nearest building ❑ Distance to nearest lot line___________________________________ Remodeling and/or repairing (describe)____________ ____ lam-- ------_----------- ---------- •_ _----, ---------------------•-----------------------------------------------------------------------------------------------------••------------------..------------------.--------------:-.----------------------- ---------------- I hereby certify t + I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances,'Stat laws, nd rules and regulations of the San Joaquin Local Health District. _...- •-------C � --' �----- --- r� (Ower and/or Contractor) (Signed) ----------- By:--- -- (Title)-------------- ; (Plot-,plan, showing sire 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-u---•----•---•-------- - - --------------------------- REVIEWED BY -------------- ------------------------------------------------------------------- DATE- Z-------------------- BUILDING PERMIT ISSUED ------ ------ DATE----- 9� Alterations and/or recommendations:.._.'------------------ --------------------------------------------------------------------- -- -------------------------- ------- ------------------------ ---------------------------------------- ----------------------------••----••------------- ----------------------------- --------------------------------- --------------------• -------------- --- •-----------••-------- - ------------------------------------------- --- --------------------------------------- ---------------------------------------------------- FINAL INSPECTION BY:-------- t Date-------- _(__ 'S! `� i --- ------------------------------------ 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-9-21A '-145446 aTwooD 1Z-54 - '