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APPLICATION FOR SANITATION PERMIT Permit No. . _T•- (Complete in Duplicate) " Date Issued ._'3_ .5"'S_ Application is hereby made to the San Joaquin Local Health District for permit to construct and install the work here' This application is made in compliance with County Ordin nce No. 544, en described. JOB ADDRESS ANLOCATION---------�J_" ------------ Owners Name--- ------- ------------------ --------- m...:. - -•----• --------------------------------- Address..-- :: Phone -- ----- - ---- ------- --- Contractor's Name--- ��•, - �a---•---- = /' / - - - ----------- ------- Phone_! Installation will serve: Residence - •- • rtment House ❑ Commercial ❑ Trailer Court � Number of living units: _ ---_ Number of bedrooms _""3__ Number of baths "� ❑ Motel ❑ Other ❑. --- Lot size _-__ -_ V ^ _'fi Water'Supply: Public 's stem T-,/�-"_2-- Y ❑ Community system -_""""" Y Y ❑ Private Depth to 1Na}er Table ft. ~ Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam Clay F Previous Application Made: Yes ❑ No A---New ❑ Y ❑ Adobe Hardpan ❑ Construction: Yes �I�o"❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permi+ted if public sewer is available within 200 feet.) ' Septic Tank: Dista ce from nearest well_-_ Q- Distance from foundation_--_�_b_ --.Material_"" No. of compartments----------�- "� " ------- ------ -- -"-- Size 0-------Liquid depth - -41 0------ Dispos Id: yI -----------Capacity-" sx----------- NDistance from nearest well-_ 'S'r-0-_-Distance from foundation_--j-0_' "","_Distance to nearest lot line"""ea e "" ..� umber of lines------- "_-_-.---/------__ Length of each line_____-_ ,4 Type of filter maferiaL"""�_ 'r g Width of trench- " �l__"""" "__"-"-"__"__ --_.17 Depth of filter material_"__� '------Total length-------- Seepage Pit: w. Distance to nearest well----� Q"� "Distance rom f undation_--_1Qt�"f.Disfance to nearest lot Number of pits--- /-------------Lining material-�--- . Size: Diameter_---_`_�'--- Depth---- ' .Q_!---------------- Cesspool: Distance from nearest well-----------------Distance from foundation_-.I-__--___ ""-_.Lining material""._"-_ "._"" ❑ TSize: Diameter--" -. r-T Depth - - - - - --------------------------- Liquid.uid Ca aci " Privy:` Distance from nearest well -- -""-, ... ' q p }Y --------- --------gals. . \ - = ----------------------Distance+from nearesf building--' ❑ - Distance-to nearest lot line.-._`- - Y 1 --------------------------------------------------------------- Remodeling and/or repairing (describe):-------------------------------------------------------- } ---------- If [ -----------------------------•------- ___-_-__ard'."_"""_-----_"-"""_-__••-'_•__---------•-.-----------------------------•--------------•----"-----------------------••------------------------------. " I hereby certify that I have prepared this application and that the work will berdo ' din accordance with San Joaquin County ordinances, St a law and rules and re ulations of the San Joaquin Loc Health District. (Signed)-- -- `~" ----••--------- -- ------------- •------------ By:_•__" •• _ r Contractor) or) ----------------------------------- size . ( ) r. (Plot pian, showing of lot, location of system in tela+ion to wells, buildings, etc., can be placed on reverse side). �'+"------- --- -- FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY -------- --------------------------------------------------------- DATE------- REVIEWED BY----- ------------=------------------------� -------------------------- -.. .""."--------------------------------�--:- -- ------------------- -------------•------- DATE-------: ------- BUILDING PERMIT ISSUED:.---_---••------""---- •-- : Alterations and/or recommendations:- - S ----------------------------------------- DATE. - -- -- ---------------------------- --- -- --- ---------------------- t ----------------------------------------------------- ----•-------------------• -- --------•--------• - FINAL INSPECTION ----------- V-5 I 3 —� - /� Date =-=------ SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 Wost Oak Street 132 Sycamore Street 814 North "C" Street ,Stocktort, California Lodi, California• Manteca, California Tracy, California ES-9-2M , , Revised W2100 T "