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APPLICATION FOR SANITATION PERMIT Permit No. _3__�.___�___9 1 Pet (Complete in Duplicate) Date Issued ________ _ �✓ i Application is hereby made to the San Joaquin Local Health District for a perm't to construct and install the work herein described. This application is made in compliance with County Ordinance No. 549. JOB ADDRESS AND LOCATION -- ---- ------ ---------------------------- --------- ------------------------------------------------ Owner's Name-------- - Phone---------------------------- Address---------------- ------ -- ----------------------------------------------- - ----- -------------•--------•------------------------------------------ ------ ------------ -- -- ----- - ---- ---------- - Contractor's Name---__ -- -- - -`---- - -- --- --- ---_ _- �----- - -_ ��------------------- Phone --- C/_-STC/_----- Installation will serve: Residence -Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: _/___ tuber of bedrooms __/__ Number of baths -L-__ Lot size ____- —Xl—td_________________________ Water Supply: Public system Community system ❑ Private ❑ Depth to Water Table -------- ft. Character of soil to a depth of 3 feet: Sand ravel ❑ Sandy Loam ❑ y Loam ❑ Clay E] Adobe Hardpan E]Previous Application Made: Yes E] No New Construction: Yes No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public seyge is available within 200 feet.) Septic Ta Distance from nearest we l V - isfance fr foundation___ /. --�---------.Mat - -- - - - --�--s---• -00 No. of compartments_-_ ------------- -- i. __ _____Liquid depth---- �'__�`�__ Capacity____� �--_ Disposal Fi Distance from nearest we.146 �istance from foundation,��___________Distance to nearest I t�ne_ ______ Number of lines____ !.__.__ ____/Length of each line______(041--__ Width of french----2-- Type of filter material-s7i _ .-Depth of filter material---�_77___-_-___Total length____--G� ---------------------------- Seepage Pit: Distance to nearest well----------------------Distance from foundation--------------------Distance to nearest lot line----------------- El Number of pits----------------------Lining material-----------------------Size: Diameter------------------------Depth--------------------------------- Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material------------------------------------- ILA ❑ Size: Diameter--------------------------------------Depth----------------------------------------------------Liquid Capacity----------------------------gals. O Privy: - Distance from nearest well_______ ----------------------------------------Distance -from nearest building____-__________________--_____________- � /� ❑ Distance to nearest lot line-------------------- --------- ------------ -----•--- f ti!' Remodeling and/or repairing (descril8e):----____-_4 __ �►�f//]r --- ----- -----f__SG�_r-•--- -•-- --- ---------•---- --- —��y- ------------------ --- - li • t ---------------------------------------------------------------------------------------------------------- -------------------------------------- ------- ----- ---------------------------- I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, Stat laws, d rules and re ulatio s of the San Joaquin Local Health District. (Signed) �� .. " ' (O . er and/ Contractor) BY: 6:.. t } U/-- -------------------------------------------------------------------------------------(Title)----- ...... ................... (Piot 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---- q —--------------- REVIEWED BY DATE - BF�Z�� -- BUILDINGPERMIT ISSUED------------------------------------------------------------------------------------------------------ DATE-------------- ---------------------------------------------- Alterationsand/or recommendations------------------------------------------------------------------------------------------------------------------------•--------------------------------------- ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ------•-----------------------------------------------•------------------------------------------------------- ------------------------------------ ----- ---------------------------------------------------------•- FINAL INSPECTION $Y:- M Date 1/ -----------•------•------- 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 5-51 Revised W-2100