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APPLICATION FOR SANITATION PERMIT Permit No. ...L.S. - � p)0 (Complete in Duplicate) y/ S` - Date Issued --- Application is hereby made to the.San Joaquin Local Health District for a permit to construct and install the work herein described. This application is made in compliance with County Ordinance N249.. 49., JOB ADDRESS AND LOC ATIO -/_?__.__ - ------ ------- ----------------- Owner's Name--- ,6i 10 a -- --------------------------------------- Phone-------------------------------•--- Address------ --- - - - ------- Contractor's Name.- _ _ _-. _ *,�i��-'----- ,v� ------------------- - Phone----------------------------------- Installation -------•------------------- - - Installation will serve: Residence *-_Zpartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: J___ Number of bedrooms .. Number of baths _/-... Lot size - Water Supply: Public system P__'Community system ❑ Private ❑ Depth to Water Table _071ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam [❑ Clay ❑ Adobe 0]"`H'_ardpan [] Previous Application Made: Yes ❑ No ®r New Construction: Yes ❑ No R9-'THA/VA: Yes ❑ No 9-- TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank ar'cesspool permitted if public sewer is available within 200 feet.) Septic Tank: Distance from nearest well------------------Distance from foundation---. _------.•__.Material. ........___.. _-....-... ❑ No. of compartments---------------------------Size........•-----------------------Liquid depth--------------------------Capacity------ --------------- Disposal Field: Distance from nearest well------------------Distance from foundation---------- --------Distance to nearest lot line_- ._....---- ❑ Number of lines---------------------------------._Length of each line------------------------------Width of trench----------------------------------- Type of filter material---------------------- Depth-of fil"t r'material-----------------------Total length-----------.-_..__..__---._.._..._...---._ Seepage Pit: Distance to nearest well. /A ,0_f _ istance r m fou ation___� _.....Distance to nearest lot line__ --�-- p� Ips Number of pits.... ...............Lining material1�L�Size: Diameter-_113_ ..:.---Dept h---A.n'S.` ............... fV 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 �--------- ----- ----- --- -- --- ----------------•--------= _--------------------- - ------------------- -- Y Remodeling and/or repairing (describe)_______ ---------------------•---------------------------------- -------------------------------------------------------•------------=--------------------------------------•--------------------------------------------•------------------------------------------------------- -------- ----------•=--------------------------------------•--------•-- ------ I hereby certify that I have prepared this application and that the work will be done in accordance with San Jo. ,i quin County ordinances, State laws, and rules and regul tions of th San Joaquin Local Health District. (Si ned 9 )----------------- ----- --- ------- ----------- ----- "Contractor] By:--------------------------------------_- - =------ -' (Title)---- --------�----- (Plot plan, showing size of lot, Iota n of system in relation to wells, buildings, etc., can be placed on reverse ide). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY ----------------------- --------- - DATE_ REVIEWEDBY -----_- ---�---- ------ ---------------------------------------------------------- DATE.. ------------------- . BUILDING PERMIT ISSUED--------------<�-------------- ------------------------------------------------------------------- DATE _` --------------------------------------- Alterations and/or recommendations: 16W- --------------------------------------------------------------------------------------------------------------- ----- ----- ------------------------------------------------:---•-•--------•------•-------------------------------- --------- ----------------------- ------- ----------- -•------------ ----"=------- ----- ------ ------- --------- Zi;;__: - -- - -- - - - - M1 -- ---------- --- - --- - - - - --------------- : .. ---------------------- ----- FINAL, INSPECTION BY-------------- ------ -- _ Date-- -- 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 /ES-9-2M , Revises 1-57 EP.CO. —