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r APPLICATION FORSANITATION PERMIT Permit No._3___!--- / (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 Ord' o. 549. �= JOB ADDRESS AND LOCATI f ---. :------------------------------ Phone ------- Owner's Name-------- .,ar' -- � �. ------------------------------------------------------ Address.-------- --------------------- Contractor's -•-•--------- ' Phone_-------- ---` Contractor s Name--------- - - ---------- - -----------•--------------- I -----•------------------------ --- ------------ - - ----------------- Installation will serve: Residence Apartment House ❑ Commercial 0 Trailer Court ❑ Motel❑ then ❑ Number of living units: __ ---- Number of bedrooms _- Number of baths -_ ___. Lot size ....... -- - --- Water Supply: Public system Community system ❑ Private ❑ Depth to Water Table -------- ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam El Clay El 'Adobe C5-'Hardpan [I k Previous Application Made: Yes ❑ No New Construction:. Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: O (No septic tank or cesspool permitted if public sew r available-within 200 feet 1 Se d Distance from nearest we r from foundation- -- -- ateriai - ------- ----------- ------------ "..."Ln. - apacif ----_- aqu i -----Distance to nearest I t e ---Width of trench g Disposal tell: Distance from nearest wel -- -_Distance.from foundation- Number of lines-------------- ---- -----------Length of each line------____-- -- --- Type of filter material Depth of filter materia!_ _ -_Total length---:= - - -------------------------- Seepage Pit: Distance to nearest we __--- :--D•sstance from foundation -_-_.._--.Distance to nearest lot !in - --. -;-----. Size: Dia eter---------- ------ ---Deptn----------------------. ❑.� � ;. _ Number_of pits-_—Lining ma#erial_------------------ -- . Cesspool: Dista ce nearest well---�-- __-_--__Distance from foundation:._- =.lining mratenaL____ ❑ Si e: Diame#er `---------------- -----------Depth-------------------------------- Liqu'sd Capacity gals. ------ Privtante fro nearest well-------------------------------------------------Distance from nearest building--------------------4______------- ----- Y e o nearest of line--____----- ---------- -----------------------------•---------------- -_-__ y Re sling and/or rep g escribe .------ -__ -� ------- ------ = f'-----------------------•---------•------ ------------ --------------------------------------------- .. -- ------------------- ------------------- ----------------------------------------------------------------- I hereby certify that I have prepared this application and that the work ne to accordance with San Joaquin Count s ordinan e , State L and rul s an guI tions of the San Joaquin Local Health District. (Signed)-_ - (Owner and/or Contractbr) -- ------ - ------ ��. �_-- - _- } Title (Plot pla , 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-------------- ---- -- -- -----=-------- ---- - -------------------•-------------------- DATE--.- - '_` --- --------------- DATE - r REVIEWEDBY---------------------------------------------- --------------------------------------------------------- 11 --- -------------------- DATE BUILDING PERMIT ISSUED 11- ---------------•X �'- - ------- DATE--------•------�"" --------- -..--------- • `� _ 2 -" � Alterations and/or recommendations:-- � t^a-•�,+tin-----=------•:--1--•-------------`�--='�'--------�------'�_'�_..---�_-r�...-=---: -�•--- ---- d ------------------•----- ---------------- --- ---------------------------- ----------- ------------- ------------------------------- j`,------- -------- ------------------------------------ INAL INSPECTION BY:----- �=-,-"r�---�------------------------------------ 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 E5-9-2M IO's2 Revised W-2100 ,