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APPLICATION FOR SANITATION PERMIT Permit No. AP-0--2— (Complete P-0--2(Complete in Duplicate) 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 Or inan No. 5 9. I JOB ADDRESS D LOCATION..--/(. - 1 - Owner's Name s ------•--- /---------•- Phone s• ---------------- --- Address------------------ = ' I ------- -------------------•------------------------•---------------------------------------- Contractor's Name_ � ""� - Phone -------------------------------------------- ---- ;;; Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Mote9l ❑ Other ❑ Number of living units: ---I__ umber of bedrooms -Z Number of baths ._.f.-_- 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 Lo;/20 Cla� Coam*[[� Clay ❑ Adobe Hardpan ❑ _.A Previous Application Made: Yes ❑ No New Construction: Yes ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if;public sewer is available within 200 feet.) Septic nk: Distance from nearest well _ -....bistan e fro fau ion--- _....... .Mate i�l------- ------ -- No. of compartments--------- ------- ----Size--- - ----------Liquid depth----------- --- -----------Capacity----- p- 1 Dispos 1' Field: Distance from nearest well ----------------Distance from foundation- 19/.�-- Distance to nearest I �ne---�__------ Number of lines_-_..______ ___�_._--.--_----_Length of each line----------/_�d-l- Width of trench. � i Type of filter me Depth D p �] gg �7 i e th of filter materna!-__.__-�- Total length--_c--- --- - ----------- Seepage _____•_-+ _f - Seepage Pit: Distance to nearest~well--------------____Distance from foundation-....................Distance to.nearest lot line- ---_____ _ 1 - ❑ Humber of pits.--- '-------------Lining material---------------------..Size: Diamheter---------------------- Depth ' Cesspool: Distance from nearest well---=--- ------#Distance from foundation__--_---__-____.Lining material-_.-----------------._ ----.- ❑ Size: Diameter-----==�----------- ------ (Depth _" `..-.— -"- . Liquid Capacity gals. Privy: Distance from nearest well -.-.--___ -_-------------------- ts at nce from nearest building------------------------------------ Distance ___---------------- - --Distance to nearest lot line--__----'-------------------#- em® elinS Ad/or repairing (describe :___-_-._�_----_�---____-_- yUj 1 z - ... °� 0 i , ` ----•----•-I-----------"-------••----'-•----------------•------- - --•---••----- ---------------------------------------------------------------------------------- --------- ------------------------------------- -=-------------- -----•-•-------------------------------------------------- ------•--•-----a s:.--------;;:: I hereby certify that f have prepared this application and that the work will be done in accordance with�San'Jdaquin County ordinances, State laws, and rules and regulations f the San Joaquin Local Health District. (Signed) A eke r ------ .(Owner O 3 - - -- -Z ------ - - - - and/or Contractor) BY:------ ------------- y M '•/;r; ----------------------------- _ (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 5 APPLICATION ACCEPTED BY<--.- DATE- _---.•_____-__- 5=-- - - -- - - •- REVIEWEb BY------------------------------ ' --- --._.-------- ---�------------�-�---- ._- - --- ------------------•-------- - DATE----� / -V ----------------------------•-------------------- BUILDING PERMIT ISSUED. - --------- ------------------------------------------- --------- DATE--------'S` Alterations and/or recommendations------------- � ----------------------------•------•-------------------------------------------------•--------------------------------------.------------------------ -------------------------- -----------------------------•------------- FINAL INSPECTION $Y:-- ----------------------- Date Y i SAN JOAQUIN LOCAL HEALTH DISTRICT ``"''" ' 130 South American Street 300 West Oak Street 4 p �' 132 Sycamore Sfreet 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California ES-9-2M t0-52 Revised W-2100 I