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APPLICATION FOR SANITATION PERMIT Permit No.,3,- o d� l (Complete in Duplicate) Date Issued/_a/ -��S___Z - Application is herebymade to the ' `-� e San Joaquin Local Health District for a per o construct and install the work herein described. This application is made in compliance with County Ordinance'No. 549- .,� !7 3 Asa—o 6 JOB ADDRESS AND LOCATION , _- -ara4a�e.__Q71_ - � � Owner's Name---- = aU =--------- - -- -- -:- . Phone-------------- : Address -- -•------ ^ - I Contractor's Name--•---- 2 e ---- --------------- -------------------------------------------- Ph in e--�� _ Installation will serve: Residence Apartment House [] Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: - : Number of bedrooms Number of=-baths}lot size ---lid_' X `f - --- -f--"--- I Water Supply: Public system Community system'❑ Private'❑ Depth to Wa'f&'Table------------ ft." Character of soil to a depth of 3 feet: Sand E] Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobes Hardpan ❑ Previous Application Made: Yes ❑ No New Construction: Yes M_No,❑ TYPE OF INSTALLATION AND SPECIFICATIONS: ' (No septic tank or cesspool p6rmitted if public sewer is available within 200 feet.) Y. Septic Tank: Distance from nearest well-Ab71�--_Distances from foundation--_- --, _� ---__--.Material_- __- No, of compartments p /C Size "� '+-----.Liquid depth_- :"`----- Capacity-. Q �� Disposal Field: Distance from nearest well-;_ Lbs�_.Distance rom oou_n aation__I--3-_---__....Distance to nearest lot line__- Number of lines--- ------------__Length of each line_.___ -.Q-_r___----._.Width of trench-._'jAl --------------- Type of filter material --� b -Depth of filter mat rial--__--/_&-`!-----Total length-!-------- ---___ - Seepage Pit: Distance to nearest well �_ -_-pistance fr foundations f F -� _,.--..Distance to nearest lot line-__ -57 - Number of pits=_ _--- -_-_ Lining material _ Size:_Diameter__--_ i ---- �� Depth- ` ------ Cesspool: Msfance from nearest well_----------------Distance from foundation__---.-_-.-_ ---..Lining material_------------------------------ ❑ Size: Diameter-,'_-__---------------------------- -- "Depth-----------------------------------.-- - Liquid Capacity ------gals. Privy: Distance from nearest well--- ---------:----------------------------------Distance from nearest building-----------------------------------Distance to nearest lot line----------------------------------- f ---------_ 1 ---------------------------------- ` ( t Remodeling and/or repairing (describe):___--__-__-__ --------------------------------------•-----------------------------------------------•---------------------•--•--•----------------.----. -• --- f ,.-- II t '�• - ----------•--------------------------------------------------•-------------••------------•------------------------------------- ---- S -------------"----------------- ---� --------'------------------------------------------------------••----------•-----------------------------------l- •-----i_----------_--------------- I hereby icer+fy thaf I have prepared this application and that the work will`be done in accordance with San Joaquin County ordinances, St a aws, and rules and regulations of the San Joaquin Local Healfh District. a (Signed) X1,€0-p � I (�, --------•------------ �� By:------------------�. 3 t.locat_ I ----------------------------------- 4-------(rifle)------ .e�!'Yl-P=;T' act /� ontr or) (Plot plan, showing siz� of lot, Iota+ion of sys m in relation to wells, buildings, etc,ican be placed on reverse side). ' FOR DEPARTMENT USE ONLY d' APPLICATION ACCEPTED BY-----------?.___---- -- ` DATE`__--..-._- - � ' ---- ----- REVIEWED BY------------------------- - �-;--- - ---•-------- ---------------- BUILDING, ------------- --- - ----- DATE---•----------------------------------------- - ----------------- - ---------------------- BUILDING, PERMIT ISSUED --------------------------------- f ----------------- --------------•------------- DATE-- --------- ------------------------ Alterations and/or recommendations:--t----------------- :f --------------•---------•---------------- ---------- ----------------------------- -------------------------I------------- ---------------------------------------------------------------------------------- --------------------------------------------------------- -------i ------------------------------------------- ----------------!------------------- --------------------------------------------------------------------------------------------- -------------------------------------- - ------------------------------------------------------------------------------------------------------------------------------------------ ----------------- --------------------------------------------------------- ------- ------ ------------ ---------------------------------------I-------------- ------------------------------------------------ ------- ---- ---------- FINAL INSPECTION BY:---------- r Date- , I--- / - --------------------- -------------- 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 Jo-52 Revised W-2100