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5� APPLICATION FOR SANITATION PERMIT Permit No. -_. ..-3 (Complete in Duplicate) / - Date issued I-----:_- 1. :�'Sz Applica+ion is hereby made to.the San Joaquin Local Health District for a permit to construct and install the work herein described. 4 This application is made in compliance with County Ordinance No. 549. JOB ADDRESS AND LOCATION_-_-------------------------------------W ------ Owner's Name----------- ------- --------- �1 ✓'v. ��' --•--• ----- --- -- - -- --------------------------------- --------- Phone- - -- - - ---------------- Address---------/�-�-------------- -----------------------------•---•--•-----••---•--------------------------------------------••- ------------------------------------------ Contractor's Name----------- _ -------------------•---------------------------•---- Phone----------------------------------- Installation .f±------------°-----'---.-----Installation will serve: Residence 23"Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: J__- Number of bedrooms _- !'- Number of baths _-k- Lot size --_ Water Supply: Public,system ❑ Community system [Private ❑ Depth to Water Table '�Q_ ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe 0—Hardpan ❑ Previous Application Made: Yes ❑ No [4"'New Construction: Yes �o ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: V (No septic tank or cesspool permitted if public sewer is available within 200 feet.) 0 7A- Septic Septic Tank: Distance from nearest weIL10_Q-------Distance from foundation__/A---......Material____':7'_ell --- /G/ '-___________ No, of compartments--------2---------------S ize-S6_"X lL"._-_,_-_Liquid depth-----y _f__----.-Capacity.._X�SO---j DisposaTr"l Field: Distance from nearest well/64 Distance from foundation---�-e>--- ---.-.Distance to nearest lot line--�-_-----._. Number of lines---------/---------------------Length of each line-----3d ---------------.Width of trench----�y-"------------------- Type of filter material-_S! Q-_ !'.___Depth of filter material----1A_`-'---_.__Total length........ 4---------------------------- Seepage - ----------------------See a e Pit: Distance to �arest:w/eli_LD- -------- D ;rom foundation n / Distance to nearest lot lin e__��-------- humberof piLining materias k-5ze: Diameter---3k. Dept ---------------------------- Cesspool: S Cesspool: Distance 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-------- --------------------x ---------------------- -------------- - . y Remodeling and/or repairing (describe):--------- -------------------------------------- -----------------•---•--•-----------------------•---•-----------•----------------------------. - d -------------------------•----------------------------------------...-.-..---------------------------------------------•----------•------------------------------------------------------•-•---•----------------------------- ------------------------------------------ ----------------------- -------------------------------------•-------------------------- --------------------------•-------------------------•---------------- I hereby certify that 1 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. (Si ned "�— � { 9 ]------ •-- ---------------- ------- - - - - - -- ------------------------------------------------------------ (Owner and/or Contractor) gY: r !L.-P ---� - `--------------------------- (Title] fe — -------------------- (Plot plan, showing size of lot, location of syst. hn_rrelation to wells, buildings, etc., can be placed on reverse side). { a FOR DEPARTMENT USE ONLY' APPLICATION ACCEPTED BY----------------- _------------------------------- ------------------------------- DATE[r�l -'f"G--•-------------------- REVIEWEDBY-------------------------------- ------------- --- ------------------------------------------------------------------------------- DATE BUILDING PERMIT ISSUED------------------------- - m- -------.DATE.------------------------------------- Alterations and/or recommendations---------------------------------------------------------------------------------------------------------------- -------- ------------------------••---------- -----------------------------------------------------------------------------------------------------------------------------• -------•---•------------------------------------------------------------------ --------------------------------------------------------------------------------------------------------------------------------------------•-------------------------------------------------------------- ----------------- -------------- -------------------------------------------------- -------------------------------------•-•--------------------------------- FINAL INSPECTION BY------------------------"-__.__---� Date-------- 4 --- -._. 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 .S-9-2M Revised W-2100