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APPLICATION FOR SANITATION PERMIT Permit No. -3-1__4_ _- I� 50 (Complete in Duplicate) Date Issuedbl- - dj r � Application is hereby made to the San Joaquin Local Health Distri.ctfor a permit to construct and install the work herein described. This application is made in compliance with County Ordinance o 49. JOB ADDRESS LOCATION ' .; --- - ----- --- - ---------------------------------- - - - - ---- ------ Owner's Name-------q---- -- ----- - ----- ----------r--- --------- - - --- ----- Phone f Z-_L� ------------------ Address-•-- ----- - ------ i-------------•-------- -- ------------- -------------�------------------ -- - ----------------------------------- ---------------••---------__� Contractor's Name-- ------- -- --•------------------------------------------------------------------------------------------------------ Phone----------------------------------- Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court E] M Motel L] Other Number of living units- ___ __ Number of bedrooms _Z__ Number of baths ___!____ Lot size Wafer Supply: Public system Community system ❑ Private ❑ Depth to Water Table ________ ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel [:J Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe eHardpan ❑ Previous Application Made: Yes ❑ No ©1-� New Construction: Yes VNo ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No sepfic tank or cesspool permitted if pu �i sewer is available within 200 feet.) Q Septic Tank: Distance from nearest well___`�" '✓--Distance from foundation----1 _ _0 ___-___.Material____-__ !`'-'--------- Septic �- - 5 X'--47 K .5 Liquid depth------`LO�� Capacity-------�OD_---- No. of compartments__________u ____Siz _ Dis osaI Field: Distance from nearest well__ ____________Distance from foundaticn_J.__�4_--_----Distance to nearest lot line_____�4 _______ Number of lines-------------V!-----------------Length of each line---------- .............Width of trench---------Z f�-------------_- V Type of filter material____--_ Depth of filter material_________!_-------- length-------------l_�-Q_-___--____________ v ' Seepage Pit: Distance to nearest well----------------------Distance from foundation--------------------Distance fo nearest lot line_____-----.-_____ 1J�+ ❑ Number of pits----------------------Lining material-----------------------Size: Diameter------------------------Depth--------------------------------- ` 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----------------------------------------- Ch ❑ Distance to nearest lot line----------------- ---------------------------------- ----------------------------------------------------------------------------------------- R Remodelingand/or repairing (describe)-------------------------------------------------------------------------------------------------------------------------------------------------------- ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- y I hereby certify fha+ 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. -------------------- ------------------------------------------- Owner and/or Contractor (Signed)--------- ----------------------------,----- ----- - - ------------ ( By: # '`s. ��-------------------------------- {Title] (Plot plan, showing size of lot, location of system in relafion to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED �BY---------- ----------------------------------------------------- DATE-------- -�--f-5-=-�----------------- REVIEWEDBY-------------------------------------- ----- ------------------ ---- -------------------------------- DA1 E PERMITISSUED------------------------------------------------------------- --------------------------------------- DATE------------------------------------------------------------- Alterationsand/or recom endafions-----------------------------------------------------------•------------ ---------------------------------------------------------------------- ` � -- ---- -------------- �--l----- - ------------- ® f,�,, 1 I ------------- -- --------------------------------•-------------------------------------------------------------------------------------------•--------•------- ----------------------------------------------------------------------- FINAL INSPECTION BY:_______/01: __ _ -- -- --------------------------------------- Date----�-�--- ---�---- t --�---'--s---------•---------------------------- 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 8-51 Revised W-2100