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APPLICATION FOR SANITATION PERMIT Permit No. ► 3 S 4 . ----------- (Complete in Duplicate) Date Issued -`-f-—-^4_( Applica+ion is hereby made to the San Joaquin Local Health District for a permit to construef and iinstall(the work here described. This application,is.made_in.,compliance with County Ordinance No. 549. `1(303 j � - 1e(�K�A- � t �� q JOB ADDRESS AND LOC}S,TION--Av--— ----- --- LC ._-1.F .. r " �- Owners Name--.-,_ r - =-,`------------------------------------------- Phone Address - Contractor's Name r` ----- '. .I----------------- Phone----••--------- Installation will serve: Residence ❑ Apartment House ❑ Commercial E Trailer Courtlit Motel ❑ Other ❑ Number of living units: -------- Number of bedrooms ._------ Number of baths ----- Lot size .......... _ Water Supply: Public system ❑ Community system ❑ Private A Depth to'Water Table t�j_ ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe Hardpan ❑ Previous Application Made: Yes ❑ No ❑ New Construction: Yes10No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if pu6iic sewer is available within 200 feet.) 4-- Septic Tank: Distance from nearest well-- Distance from foundation--------------------Material--.---- ------- ❑ No. of compartments---- --------------- 'Size------------------------------..Liquid depth------------- -----------Capacity Disp I Field: Distance from nearest weli--/.DDistance from foundation----t#01-------Distance to nearest lot line./d.4----- (N Number of lines-------------------------- --- ---Length of each line------------------------------Width of trench-------- , Type of filter material_-- ---Depth of filter maferial---- ��----___Total length-__- ----------------------- �J it: Distance to nearest,well�_---,CA.6:t-_-Distance from foundation_----10a�'_.-:Distance to nearest lot line---- O �. eepa�e P 7��( Number of pgh;_. .__.__----.Lining material- .Size: Diameter-_--. -fit__--.._--_ Cesspool. Disfance,from nearest well-------------- Disfance�from foundation................. Lining material--.___-----_--.------_- .- ---------- ❑ Size: Diameter Depth ---------------- -------:-----Li Liquid Ca Capacity gals. Privy:w Distance ,rom.nearest well--------------------------------------------------Distance from nearest building ❑ , Distance to nearest lot'line Rsmd� ` or repairing (describe):----- �'. ----------------------•----------------- -- •-------------------------------------------------------------------------------------------------------------- �. - --------------------------------- --------------------------- ------------------------------------------------------------------------------------------------------------------------- ------ \`n} _.,. -------------------------------------I-----------------------------------M--------------------------------------- ------------------------------------------ ----------------------------------------------------------------- I'hereby ------•-------- -•------------=----- I'hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, Sta laws, and rul4ndd-regulafions of the San Joaquin Local Health District. a(Signed) <„; ---- By: = T a Contractor) - - - Title �. (Plot plan, showing size of lot, locaf ion of system in relation to wells, 6uildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY- DATE REVIEWEDBY ------------- --- ------------- ------------------ --- ------ DATE - ----------------------------------------------- UILDING PERMIT ISSUED.--•--------------------=---------------------------------------------------------------------------. DATE-------------- Alterations and/or recommendations:--_------ ------------_--_--_ __ •----------- ------ --------------•---------- --------_ --------------------------------------- - FINAL INSPECTION, BY: .. f -�� -- -- -- --- - - -1---- -----•• -- Date---- r`=------------ - -------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street `e, 132 Sycamore $frost 814 North "C” Street Stockton, California Lodi, California Manteca, California Tracy, California ES--9--2M � ' Revised W-2100