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APPLICATION FOR SANITATION PERMIT Permit No. �-4"-`-�------ (Complete in Duplicate) Date issued - 3 -- ___ cal Health District for a permit to construct and install the work herein described. Application is hereby made to the San Joaquin Lo This application is made in compliance with County Ordinance No. S49.' •t' - - ------------------------=---------- JOB ADDRESS AND LQCATION___-____A__ -"---- • v - --- ------- -------==----- Owner s Name------- _ - ------- ------------------------------------------------------_ 1,Jw t ---•--------------••- Address----•-------•------- 7 Phone = ---- ---- Contractor's ame---------------------•---=-------- 'T� Other El Installation will serve: Residence artment House ❑ Commercial F1 Number Cour} ❑ Motel ❑ • ,$ Number of baths OZ-tot size - fir ` •--------------------------- Number of living units: _____f_ Number of bedroom -----e Private Dept to Wafer Table% ft. Water Supply: Public system gR Community system ❑ ❑ p ClAdobe ardpan ❑ C aracter of soil to a depth of 3 feet: Sand F-1Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Previous Application Made: Yes ❑ Noj New Con•sfruction: Yes 8-11Lo ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) -0---- -----Ma\erial_ 7 Septic Tank: Distance fromi nearest well�.1�_'�____Distance from foundation_. � "_;_ No. of compartments------- "----- -------Size__��X-��-`�---------Liquid depth---3---�-�'._.-----rpaci' tY- _ Disposal Field: Distance fsom�nearest well-&��•�"__Distance from founda ioQ__l0-�--------Distance to nearest lot like -- Len th of each Zine__ " �•" 0- "`Width of trench---.�+��-------------- ( Number of lines--------___ --- =- 9 �44 De th of filter material---- --------------Total leng+h-- - -------------------------- orj� Type filter material-- p Seepage Pit: Distance .to nearest well-.________ ".________Distance from foundation-------- -------Distance.to nearest lot line"____.________.._ ❑ Number of•pits------------------ -- Lining material-----------------------Size: Diameter--------------- `---- Depth--------------------------------- f Cesspool: Distance from nearest well-----------------Distance from foundation.------------------lining materia------------------------------------- Cesspool: _ ..._-_-..-"---- ----- gals- Size: Liquid Capacity 9 ❑ Size: Diameter----- --===�------------------------ p ' Privy: Distance from nearest well___.__-____-:.__t_ ------Distance from nearest building-------------------------------------- ❑ Distance to nearest lot line--------------------------------------- ------- ---------------------------------- -- ---------------------- ----------------- Remodeling and/or repairing (describe):--------- -------------------- "__------------------ _"- --------------- ------------- - -------------- f hereby certify that I have prepared this application and that +he work will be done in accordance with San Joaquin County ordinances, State laws, and rules and r g"uiations of +`e.,San Joaquin Local Health District. $ .: ra�� .I - -Owner and/or Contractors (Signed)- �--C`', - _ �; -------------------------- - . � Title By----------------------------------------------------------------------------- "== - = (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 DAT --------------------•--------------------------------------- APPLICATION ---- ------ ------- ------ ------ -- APPLICATION ACCEPTED BY--------- --- ------- --------- ► __ DATE--- '� BY------------------------------ ----- ------------ - ----------------- REVIEWED ... DAT ---------- - BUILDING PERMIT ISSUED_-___.-___- _ r� rti �� -' Alterations and/or recommendations:____ ---------------------F.-------." ----------------- ------------------------------- ._ _ �� Date.------ ` ' "`"" ' ------------------- ------------------------------ FINAL INSPECTION BY:. --------------------- SAN-JOAQUIN LOCAL HEALTH DISTRICT ; 30D West Oak Street 132 Sycamore Street 814 North "C' Street 130 South American Streot Trac California Stockton, California Lodi, California Manteca, California Y G ES-4-2M io-sz Revised W-2160