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APPLICATION FOR SANITATION PERMIT Permit No. 3;, ____(Complete in in Duplicate) Date Issued ____1- 71-� I t Application is hereby made to the San Joaquin Local Health District for a.permit to construct and install the work herein described. f This application is made in compliance with County Ordinance No. 549. JOB, ADDRESS AND LO TION-------- Q = r t.. C� - -c------------------------------------------------------------------------- Owner's Name = f_ ' __lf °:1_ ---------C - = -G �y�,i Phone v -gid. ----------------------------------- Contractor's Name------------------------------------------- -----------•---------------------------------------- ---------------------------------------------Plrone----------------------------------- I Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ I Number of living units: I____ Number of bedrooms ---?---:--Number of baths .__l.. Lot size ....... A.-2Q42--------------------- 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 E],-„Clay Loam ❑ Clay ❑ Adobe Pg Hardpan ❑ Previous Application Made: Yes ❑ No ® New Construction: Yes,❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or Cesspool permitted if pu lit sewer is available within 200 feet.)_ } _.___Distan� . fro rfo,Pnd tion___Z�_____._--Material-&O- ,W-.041---------------- Septic Tank: Distance from nearest well___________ �P� � 14 No. of compartments________r�r...____- --_Size___Q..!-!__��_5____�Liquid depth---�� ..______._.Capacity--- 14 Disposal Field: Distance from nearestweli_� - __Distance from foundation.----/Q_*____.Distance to nearest lot line____ __F____ Number of lines_____________-/______._- --------Length of each line------ �_ - -f;-----.Width of trench._._ _ 4el__..__._________ Type of filter material----5,..eo--.Depth of filter material------ length-----------4__0_____________________ S I __ _.Distance from foundation_____ _ _ ..- Seepage Pit: Distance to nearest well_. ,�.(�-�____.Di tante to nearest lot line_____________ �I Number of pits- -_� ____Lining material- �AJ__+tiD_':�Size: Diameter___'�_;4'5_____.Depth------/0-: ________________ Cesspool: Distance from nearest well-----------------Distance from foundation------------.------ Lining material Size: Diameter------ I------------------------------Depth------------------------------------ ------------Liquid Capacity------.-------------------gals. l Privy: Distance from nearest well- ---------------------------------------------Distance from nearest building.__________________-_____________.__...-. ❑ Distance to nearest lot line------------------------- -----------------------------------------------------------------=------------------------------------ - ----------- Remodeling and/or repairing (describe):--------- --------------------------------••---•----------------------- ------ -- -----------------------------------------------------------------------------------------•---------------------------------------------------,------------------------------------------------------------------ --------- I 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 re}gulations of the San Joaquin Local Health District. -----------------------------------=----#--------------------------------------------------------------------------------------------------------- Owner and/or Contractor [Signed}-------�------ [ / ) By---------------------------------------------=-------- -----------------------------------------------------------------------------(Title)----------------------- ---------------------- -------------- - [Piot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side].. FOR - ART M NT USE ONLY APPLICATION ACCEPTED BY r 2 ------ DATE--------- -7- ---:) 5�- ------------------ REVIEWEDBY---------------------------------------------------------- ------------------------------------------------------------------ DATE------------------------------------------------------------ BUI LDI NG PERMIT ISSUED---------------------------------------------------------------------------------------------------- DATE------------------------------ ------------------------------ Alterationsand/or recommendations---------------------------------------------------------------------------------------...---------------------------------------------------------------------- ------------------------------- ----------------------------------------------------------- ------------------------------- - -----------------•-------------- -----------------•--------------------- -----------------•------ ---------------------------- FINAL INSPECTION BY----------------- — `'✓-------------------------- Date :`---- z T 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 10-52 Revised W-2100