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APPLICATION FOR SANITATION PERMIT Permit N _. 4 --- �� (Complete in Duplicate) Date Issued r/--Y .. Ap,�Ve6tion is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein descr'sbed. I This application is made in compliance with County Ordinance No. 549. - JOB ADDRESS AND LOCATION----------------3-7-1--1 ----------------------------------.. . -- ---------------------- Owner's Name----------------------- - � Phone Address-----------------•------------------------------ ---------------------------------------------------------------------------------------------- - Contractor's Name-----------------------idenca"rtment House ❑ Commercial ------------`--------------- Phone---------------.----------------•-- Installation will serve: Res [p,- p � ❑ Trailer Court ❑ Motel.❑ Other ❑ ' ��'�'� - - ---------------------- Number of living units: ___1__. Number of bedrooms ___v"Number of baths ___I___ Lot size ______.__,r� �- ��"°� Water Supply: Public system ❑ Community system ❑ PrivateK Depth to Water Table -------- ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Ciay Loam ❑ Clay ❑ Adobe�K Hardpan ❑ I Previous Application Made: Yes ❑ NoS4 * New Construction: Yes�< No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS. } (No septic tank or cesspool permitted if public sewer is available within 200 feet.) I r, ; 4 1 Q---.----_.Material Septic Tank: Distance from nearest weft_ Distance from foundation_ Liquid depth---------- 4 � No. of compartments------- -- -- ---------Size__ Capacity � J is�posal Field: Distance from nearest w 11___�? ____._-Distance from foundation_____ _______Distance to nearest lot line_- --------- D1 Number of line --- __-----------------Length of each line___-------1.1,---- Width of trench___-__.__ " ��"`"` Type of filter material___ _ _�____ y_ e th of filter material_____-gi�_______Tota4 length______ _______-_-_____.____ 'D p �e�tt Seepage.Pit:' Distance to nearest well__________________ Distance from foundation ______.Distance to nearest lot line_______._________ ,��l�" Number of pits = `Lining material-----------------------Size: Diameter----------------------.Depth--------------------------------- W Cesspool: Distance from nearest well ________-------Distance from foundation___________________Lining material-------------------------------------- F] -_-______________- ,___________- ,5 Size: Diameter_ __ -- --Depth__ ----- ----- ------ --- - ----- Liquid Capacity------------------------- ---------------------------- -- s ❑ _ r..r '_ Distance from nearest ildin9 .,..k �_. - , .;. bu �. Privy: Distance from nearest well____ ____ _____ ____ ____ ----------- ❑ ---------------------------------------- Distance to nearest lot line ----•---------- ------------------------------------------------------- El - ----------- ------------------------ Remodeling and/or repairing {describe)= ---==----- ---- ---------------------------------------------------------- 1 --------------------------------------------------------------------------------- } -------------- ---------•--_---------------=------ ------------------ -----------•--------------------------------------------------------------------------------- -------------------------------------------------------- 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 regulations of the San Joaquin Local Health District. , ,, __.__ (Owner and/or Contractor) (Signe '=-� - � ------------------------------------------------------------------- BY] ----- ----- _ ----(Title -----------1- -- --- ---- -- --- ----- ------------ Fm (Plot plan, showmgsize of lot,1-ocatlon-of systern'in relation fio'wells,-buildings -etc.-can-6e-plaaed;on reverse side) ;. FOR DEPARTMENT'USE ONLY iE=---------- ----- -�" --��- APPLICATION ACCEPTED BY ---------------- - ----------•-- -----�--- -----'----- ------------------ ------------- DAT REVIEWED BY-------------------------------- ------ DATE------------------------------------------------------------ - ---------------------------------------------------------------------------------- BUILDING PERMIT ISSUED------------------------------- ----•---------- DATE-------------------------------------------------------------- Alterat'vn an /�recomm�d .ions:__.__._._- --.-- 1 --------------- --------•---------------------------------------------------------- ------------ ------.----- - ---------------- r - - - 11 s -----_- --------------- __ -I- ------ -4L� FINAL INSPECTION BY-------------- ----------- --------- Date---------•/----------------------------_ ---r- .............. -- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street, 132 Sycamore Street 814 North "C'• Street Stockton, California Lodi, California mantoca, California Tracy, California 4 } ES-9-2M &51 Revised W-2100