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APPLICATION FOR SANITATION PERMIT Permit No- -3 ..-.�.. (Complete in Duplicate) �/ x Date Issued .----- J`_ Applica+ion is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein descri ed. This ap cation is.made in compliance with County Ordinance No. 549. isW r Acs �� JOB ADD SS ND LOCATION_ -.- _. 4 0 C� L?�►i �P ��.� ! `' -�- -------r y"[` I' Owner's Name--- "-- [- --------- --- -- -------------- -=- ------------------- ------------------------- Phone vT� Address -C �'?'1. ..._ ------ --- ---- �-�� - Contractor's Name------------------------------------- °'�. -------.�/_�•�L ,•------------- Ph e.. -_i F� Installation will serve: Residence, Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: -- --- Number of bedrooms _-1-.. Number of baths j-._ Lot size .-------1- 4%M _.---__------------------ Water Supply: Public system ❑ Community system ❑ Private, Depth to-Water Tableeft. Character of soil to a depth of 3 feet: Sand ❑ Gravel 0 Sandy Loam ❑ Cla oam ❑ Cl a ❑ AdobeHardpan f � Previous Application Made: Yes ❑ No�New Construction: Yes ❑ No ❑ ��m�rr TYPE OF INSTALLATION AND SPECIFICATIONS: f s r (No septic tank or cesspool permitted if public sewer is available within 200 feet.) is �T ` Distance from nearest well-----------------Distance from foundation--------------------Material_-__-____---:_-----------_-.____-----------. f No. of compartments--------------------------Size-------------------------------Liquid depth--------------------------Capacity---•------------------- os dDistance from nearest well------------ Distance from foundation--------------------Distance to nearest lot line----------------- umber of lines-----------------------------------Length of each line------------------------------Width of french----------------------------------- T of filter material------------------/--Depth of filter material----------------------- length_-_-.--------_._----___-----_------_---_-- 100 Se epa e Pit: Distance to nearest well�� -_---_Distant gr f ndation-a4-S4-._-._- istancce to nearest ! t lin -Number ofpits.---I---------------Lining materia - ��0- Isspol .---Size: Diameter .--�.--__Deptn_G _- C : Distance from nearest well----------------Distance fromunclation-----.---.-.-------.Lining material-----------------------------_---.--_. [❑ Size: Diameter-----------------•---------- --------.Depth----------------------------------- ------Liquid Capacity----------------------------gals, -._ _ 4 -.. �;" —4 — Priv Distance from nearest well________________ _ __Distance from nearest building ❑ Distance to nearest lot line-----------"--- ------------------------------------------------------------=-----=------------------------------------------------------- Remodeling and/or repairing (describe)------------------------------------------------------------------------------------- -------------------------- ---------- --- ----------------•--------------------------------------------------------------------------------------------------•----------•------------------------------------------------ I hereby ertify t at I have repared ication and that the work will be done in accordance with San Joaquin County ordinances, S e la , and rules and"re latian`s of t San J gair�Local Health District. ---- _(Signed)--------- ----- +� �� tC Contractor) By:..................................----••---•-•---------------------------------------- Title)-- �1� la�_ ----------------- (Plot plan, showing size of lot, location of system in relation to w , buildings, etc. an be placed on reverse side). FOR DEPART ENT USE ONLY APPLICATION ACCEPTED BY = DATE ,:-----:.---:--v---------------------------- REVIEWEDBY----------------------------- .-.- ------------------------------------------------------------- ---------------- DATE-_ r- --_-J----•-- -- - -•---- �� BUILDING PERMIT ISSUED------------- ------------------------------------- DATE----- ---- Alterations and/or recommendations:----------------=----------------------------------------------------------------------------------------•----- -...---------•----•-------------- - --------------------------------------------------------------- tie -----------•---------------------- ----------------- ------------•------------ ----------------------------------------- -------------------------------------------------------------------- -------------------- FINAL INSPECTION BY:...... "]�rtrr�-y!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 E�-2M ; - Revised W-2100 J