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NZ ' APPLICATION FOR SANITATION PERMIT Permit No.3-4-. _Y (Complete in Duplicate) a 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 Ordinance No. 49. JOB ADDRESS AND LOC N________- ---- --------- Owner's -------Owner s Name------------- -- ------- -- - - - -- --------------- - - ---- --------------I-------------- Phone------------------------------------ Address ,--- ------------------- ------ Address------------------------- Z ---- --- ---- --------- .� ' Contractor's Name--------- "' - � " _ Phone--- .. "°� 1 , Installation will serve: Residence Apartment House ❑ Commercial 0 Trailer Court ❑ Motel ❑ Other ❑ � of living units: ___ __ Number of bedrooms _ -_-_ Number of b Lot size ________ .__ _ -- _ -------------- Number -' ' Water Supply: Public system ❑ Community system ❑ Private epth to Water Tabl --_ __ ft. Character of soil to a depth of 3 feet: Sand ❑ ravel ❑ Sandy Loam ❑ ay Loam ❑ Clay ❑ Adobe Hardpan ❑ I Previous Application Made: Yes ❑ - No New Construction: Yes o ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet. Septic Tan Distance from nearest well tom_ _____Distance from foundation----Ir __Material-_-- .-_____________________________ No. of com artments___ Size __--Liquid de th_____ —__Ca Capacity _ ___V-�______ p // q p p Y ' Disposal Field: Distance from nearest e11_/.�/___/ __Distance from foundai L'_-_-Distance to nearest lot line__,f�_-____ Number of lines!_____ _�_____ _- ength of each line___` ---Width of trench-----�� ------------------ Type of filter material -� � =_Depth of filter material___,--___ '`________Total .length______' _ _________________________ Seepage Pit: Distance to nearest well----__________________Distance from foundation--------------------Distance to nearest lot line----------_------ El __ _-_._____-❑ Number of pits----------------------Lining material----------------------.Size: Diameter-----------------------.Depth------------------------- 1 Cesspool: Distance from nearest well --_________Distance from foundation"_____--------------Lining material---------.-------------------------__. ❑ Size: Diameter-3 ---------------- -------Depth-------------------- __ = Liquid Capaciy __ - pals.. ....~ .- m.. 9..�-- Privy: Distance from nearest well------------------------------------------------- from nearest building---._----_----___________________________ ❑ Distance to nearest lot fine------------------ ----------------------"---- ------------ -------------------.------------ ------------------ ---------------------- -T Af- Remodeling and/or repairing (describe):_________ _ __ - - --- E-110:46 -----------------------------------------•----------------- ------ '=------------------------------------------------•----------------------------------- ---------•------------------------------------------------ ---- --------------------------- - 1 ------------------------------------------------------------------------------------------------•-------------------------------------------------- ---------------------------------------------- hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, Sfafe w rand ule d regulations of)We San Joaquin Lo,61 Health District. a (Signed} -------- _ _____(Ow .and/or tractor) ,per --------------------------------------------{Title} gY� �+ A' -----------"--- (Piot pian, 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- REVIEWED BY------------------------------------------------ -- -- - ----------------------------------- ----------------------------------- DATE-------------------------------------------- BUILDINGPERMIT ISSUED----------------------------------------------------------------------------------------------------- DATE------------------------------------------------------------- Alterationsand/or recommendations---------------------------------------------------------------------------------------------------------------------------------------------------------------- ---------------------------------------- -------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- --------------------------------------------------------------------------------------•-- '. ------------------------"------------------ ------------------- -------------- --- ------------------------------------------------------------------------------------------------------------- § FINAL INSPECTION BY------------------- ---'---------- -------------- Date---------- -- ------ ------------------------------- ----- F SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Street 814 North "C" Street G Stockton, California Lodi, California Manteca, California Tracy, California E5-9-2M B-51 Revisod W-2100