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✓ 3 ° 3 APPLICATION FOR SANITATION eERMIT Permit No. (Complete in Duplicate) Date Issued _ ---- Application is hereby made to the. San Joaquin Local Health District for a permif'to construct and install the work herein described. This application is made in comply nce with County Ordinance No. 549. i ------------.------------------------- U OB ADDRESS AND LOCATION__ �' D �-- ------�--- -------c' �`'' �` ' _-------------- i`l. ® _ Phone-----------•------------•------•--- .�4 wner's Name ._.� ---- --��+---- ------'-^`�--- -------------- ----------- -------------- ------------- -- ---- = -- Address-- ----4�-2,07^ --AI ' '---------Ae-------------------------------------------------------------------------------------------- ------------------------------------------- ---------------•-•------------------------------ ----------------------------------- C i ontractor's Name__,,�*S,�•�--------------------------•------------- -------------- ------------------------- Phone-------- ------ --------------- ------------ Installation will serve: Residence El Apartment House ElCommercial ❑ Trailer Court W] Motel L] - Other [_1 Number of living units: #N umber of bedrooms -------- Number of baths Lot size ____-?1__ ____ ________------------------------ R{ Water Supply: Public system ❑ , Community system ❑ Private. Depth Po,Water Table Y0__ ft. I Character of soil to a depth of 3 feet: Sand E] GravelElSandy Loam ElClay Loam,& Clay C] Adobe ❑ Hardpan ❑ Previous Application Made: Yes ❑ 'No4 New Construction: Yes ] No ❑ rHA/VA: Yes ❑ No ❑ , TYPE OF INSTALLATION AND SPECIFICATIONS: t ; (No septic tank or cesspooll'ermmiitwteed if,.pubii wer is available within>20 feet.) Se tic Tank: Distance from nearest well___,�}'!ro______Qisfance from foundation---1p.________-Material__________________ __-------------------------- _ P No. of ccmpartments--- S e- '" ' Liquid depth = �fK ----Capacity-A-x'-`---------- . n_____-___._.Distance to nearest lot line__$-7_-______- Disposal Field: Qistance from nearest well_�UO.____._:Dis�tance from foundation___ _ Number of lines-'-----/_---------------------t__Length of each line------0�'--------------Width of trench--r�- '�---------------------- Type of filter material __lPa--'ADepth of filter material---14"--------------Total length---4!rv ---------------------------- Seepage Pit: Distance tb nearest well-----------------------Distance from foundation____________-_____-.Distance to nearest lot line----------------- Number of pits_.�- -`--'�------- Lining material-------------- ----- Size: Diameter-----------------------Depth---- ------------- - �E , Cesspool: Distance from nearest well------------- ='Distance from foundation__._______.-___.---Lining material-------------------------------------- . j ------eDe tht;--- --------------- = Liquid Capacity---------------------------gals. ❑ � Size: Diameter-------- ------ ------ - P Privy: Distance from nearest well--------------_----------------------------------Distance from nearest building__________----______________----________-El V Distance to nearest lot line------------------------- - --------------------------------------------------------- V • 3 •a' R odeling and/or repairing (describo): -._, 6__ _.�� -------------------------------------- �.: ----- -- - --- ----------------------------------------------------------------•--------------------------- -- ---- =- - - - -- -- --- -------- -""'' = * I I l 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. (Signed)_'-� _'`; --------------------------------------------------------- By: -=------ ------------ ------------- ----- __________________[Owner and/or Contractor) Title (Plot plan, 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------------------------------------t------ -------------------------- -------------- ----------------------------------- DATE----------------------------------------------------------- BUILDING PERMIT ISSUED------------+------------------- ------------ DATE------------------------------------------------------------- Alterations and/or recommendations:----------.------- --------_-•----•---------•----•------•------------ -------------- + ----------------------------------------------------------- ' -------•---------------------------------- ---------------------- ---------- --�-----•--------------------------------------- -------------------•-------------- ---------------— -------------•--•------------ ' - �• .--- 4'___�`'`"r---------------------------------------=------------- --------------------- - r --• - ----------- Date-------------------------------------- ------------------------------------- FINAL INSPECTION BY:___ ` ----""" --�-�----� SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street I 300 West Oak Street 132 Sycamore Street 914 North "C" Street ' Stockton; California Lodi, California Manteca, California Tracy, California ES-9-2MRev'sse6 1-57 F.P.CO.