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F APPLICATION ICOR SANITATION PERMIT Permit No. (Complete in Duplicate) _ Date Issued Application is hereby made to the San Joaquin Local Health District for a This application is made in compliance with County Ordinance No. 549, permrt to construct and install the work herein descri ed. '- ,� Z JOB ADDRESS AND LOCATION /jeL-r I(0 �) - f.�-V r) ......)__ Owner's Name--------------- I @!,�J4-- -_ -----------A -6 ZQ__I S- ------------ ------- ---- -----------------.. Phone__. Address---------------------------••-�•-_� fce. 0 +a� C C, - ---------------- -_-----------•----------------• ---------------•--- ------------------------ Contractor's Name ------•-------•----------- ----•-------..__ Phone-_.. ,3.1_--9 ---- -------------------------------- ------ Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: umber of bedrooms _ Number of baths /____. Lot size -------- Water Supply: Public system Community. system ❑ Private ❑ Depth to Water Table _ ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel (] Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe ❑ Hardpan 17.1 Previous Application Made: Yes ❑ No 1;K New Construction: Yes 21"No ❑ € TYPE OF INSTALLATION AND SPECIFICATIONS: . (No septic tank or cesspool permitted if public sewer is available within 200 feet.) + Septic Tank: Distance from nearest well____' --------Dista from foun ation_fO__----_ .Material__ ______________ _ No. of compartments--------�------------Size_Z(_/�/___-- ;0: -----Liquid depth------5----- ------Capacity----- .------- Disposal Field: Distance from nearest well___._`.___:_Distanceffrom foundation --_.Distance to nearest lot line___�_-- 9 Number a1 lines________—d001 � Length of each line------------6P-----------Width' of trench............. r-------- Type of filter material_)-1. ---_-Depth of filter material-_-.____IF {___._Total •length._--_______._..._ Z.±d_-----___ Seepage Pit: Distance to nearest well______________________Distance from foundation---------------------Distance to nearest lot line-------.__.-_____ ❑ Number of pits----------------------Lining material-- =---------------- Size: Diameter , Depth ---------- Cesspool• Distance from nearest well--------------___Distance' from foundation_-_._#-----------Lining material_____-____________.-_.______.___ _ ❑ Size: Diameter----------------- ------------------Depth----`----------------------t � t =-------------Liquid Capacity-------------------------------- -gals. Privy: Distance from nearest well------ t _______________________--Distance from nearest buildin ❑ Distance to nearest lot line_________________________________________-____._ Remodeling and/or repairing (describe)__________----------------------- _ ' J I E --------------- ------------- ----•----- -------------••--------•--------••-------•--------• - --- ---------------•---------------•-------------- -•--------------•---------•--------------•----------- ----------------------- I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State I s, and rules nd regulations of the San Joaquin Local Health District. f^ (Signed) (Owner and/or Contractor) ---------•---------------------- - I f By: --------------------------------- -- -(Title)---------------------------•---------------------------- ------- (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 APPLICATION ACCEPTED BY---- -------- - --- --------------------------------- ----------------------•---------------- DATE------ REVIEWED BY - -- -------------------------------------- DATE----- __.1 � BUILDING PERMIT ISSUED----------•------ - ----------------------------------------- DATEAlt $ tions and/or- -- -�_,-_-_�: ---------� -- �� .�- - �- • f era - - ------•-------•--------------••------••---•---•-----------•--------- -------------- ----------------•----------------•---------•---• -- - - - - --------------------------------------------------- ------------•---•------------------------ FINAL INSPECTION BY:---------- --------------- Date.-. 1 --------- -------------------------------- r SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Sfrest 132 Sycamore Sfreet 814 North "C" Street Stockton, California Lodi, California Manfeca, California Tracy, California ES-9-2M 10-52 Revised W-2100