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1 APPLICATION FOR SANITATION PERMIT Permit No. ._. _ _0_ (Complete in Duplicate) - Date Issued ____3 ,W5_� Application is,hereby made to the San Joaquin Local Health District for a permi to construct and install the work herein described. This application is made in compliance with County Ordinan No. 9. JOB ADDRESS AND LOCATION-=--- Cl__-C - 1 -- ------------------------------------------------------------------------------- --------------------- Owner's Name rr15" ._ Phone GG i Address___________'__0-- ---------------------------------------------------------------- --------- ---------- -••--•--------------- --------------------------------------------- e-- '-- ------------------------------- -- •--- ----•-- Phone--------•-----------•---••----- Contractor's Nam Installation will serve: Residence UK-.Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel'❑ Other p Number of living units. ________ N bar of bedrooms3_-___ Number of baths _-__. Lot size _ ------- C--_- _p_�f___________.________ 1 Water Supply:' Publics stem Communit system Private . Depth to Water Table ________ ft. k PPY�� Y Y Y ❑• ❑ P Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam❑ Clay Loam ❑ Clay ❑ Adobeardpan ❑ Previous Application Made: Yes ❑ No [9-""New Construction: Yes No ❑ FHA/VA: Yes ❑ No ❑ f TYPE OF INSTALLATION AND SPECIFICATIONS: r I (No septic tank or`cesspool permitted if public sewer is available within 200 fee .) 1 Septic T Distance from nearest well__Distance ft faun ation___ ___ _______Mat rial__�--'_ _______________ __-_-----._______- Er No. of compartments_._______________________Size__ �l Liquid depth___ _._____________Capacity �� --------------- i Disposal field: Distance from nearest wellAl _._.Distance from foundatio __/Q_______Distance to nearest lot I in __c ` Number of lines_..._ Z..... .......... ....Length of each line..... ( .......!!....Width of trench _ _ -------------------------- Type of filter material____ IC _Depth of filter material____- �--_--__.T 1 Total length_____ _ Seepage Pit: Distance to nearest well----------------------Distance from foundation--------------------Distance to nearest lot line_________________ ❑ Number of pits----------------------Lining material-----------------------Size:•Diameter_:__—__—__.=: Depths._.__.----------------------- i Cesspool: Distance from nearest well-----------------Distance from foundation-..._---------------Lining material-------------------- --------_________- ❑ 'Size: Diameter------------------------- ------Depth----------------------------------------------------Liquid Capacity... ='---------------------gals. Privy: Distance from nearest wO-------------------------_-_-- ------Distance from nearest building-----------------_.___________ ----------- ❑ Distance to nearest lot Fine--------------------------•----- -------------------------------------------------------------------------------------- - ------------------- Remodeling and/or repairing (describe)--------------------------------------- --------------------------------------------------------.----•------------------ --- --- . -------------------•----------------••-------------------------------------•-•---=----- ------------ -------------------------•-------------------------------------------------------------=--•----•------------------------ ---------=--------------------•--------•----------------------------=--------•-----•---------------------`------- --- -------------------- --------------------- ---------•-------------------------------------------------- •-------------------------------------------------------------------------------------------- ------------------- ! hereby certify that I 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. �((Signed --------- - --- J------------------------------------------------------ ----------------------- ------.(Owner and/or Contractor) i '\ By— ...............................•....................-•-----•-------•- ......-.--------------------------------(Title)-------------------------------------------------------------- i (Plot plan., lan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). s FOR DEPARTMENT USE ONLY-, * -- APPLICATION ACCEPTED BY------ •---- -----------------------------------------•---------------- DATE-----------•----------------- {� REVIEWED BY---------------------=---------------- - -------------- --------�- ----------------------- DATE S- ----•---•-- ---- BUILDING PERMIT ISSUED.-...---_-•----------- ---- -- ------------------------------------------------------------- DATE----- -- --------- ..- - - -- -------------------------- Alterations and/or recommendations.----- -- --------------------------------------------------------------------------------------•------- -.-------------------------------------------------- I ------------- -------- ----=----- ----------------------------------------------------------------------------=----------------------- --------------•---------------- •> ----------•--•------------- Z.7 y t �: --------- f� i s 'tv j------ lr u ----------------------------------------------------------------------------------------- -------------------- ---------------------------------------------------------------------------------------------------------------•-------------------------------------------- ---------- FINAL INSPECTION BY:--- -- � .-------_.__ Date-___--_f (v�= ,� 4J 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 , Revised 1.57 F.P,CO.