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t APPLICATION FORSANITATION .PERMIT Permit No.4�Aly-1 - (Complete in Duplicate) / Date Issued ! (_�31 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 Cou.t O dinance No 49. JOB ADDRESS D LOC TION _.____ - - --------- _ Owner's Name--- -• --- _ _•---- �—a� &3 ------------------ Phone--------------------------- - A dress-- - --•---- •--- Contractor's Name___ --- ------- ----- ----- ------'---------------------------•------- Phone-----•-•---•--------•-----•- ----- Installa+ion will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Moel ❑ thea ❑ - Number_of_li.ving units- ._-�-- umber of bedrooms -I• Number of baths __ ____ Lot size ___60'-A __________ __ __ Water Supply: Public system Lv1 Gommun.ity sysfe Private-[J'}Depth+to Wafer Table______ __. Character of soil to a depth of 3 feet: S; �New dGravel ❑ Sandy Loam Clay Loam E] Clay ❑ Adobe�ardpan [] Previous Application Made: Yes ❑ No Construction: Yes [ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted %ublicer is available within 200 feetSeptic ank: Distance from nearest weDistance urld 1_ _ ------- ---.Mat ri�l--- - --- EK No. of compartments ,,{ --1 zeto-'--- - ---- --- -- - ----- iquid de. h ---- Capacity �_ p Y �� - --- - r Pispo I Field , Distance from nearest 'w II!�(1_____ --- istance from foundation______ __ _ _Distance to nearest lot lin Number of lines------------ ----------- ------ -Len th of each line------__� 1 ____ . �( ' Length �/-- Width of trench__________ -- Type of filter materi _ __ �"X epth of filter materia ------- Total length--------1 Seepage Pit: Distance to nearest well_______---------------Distance from foundation--------------------Distance to nearest lot line___-.____-______- 'Qv ❑ Number of pits____________________Lining material-------------------------Size: Diameter_____________ v --- ----.Depth-------------------•---------- - 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 �- El Distance to nearest lot line_____-_.____._.___-______ Reim eli and/or repairing {descri el:._---_ ---- ------------ -------------------- ----- ------------ r" ------#- -----•------------•- - Clef ------------------------ ---------------- hereby- tify 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. r {Signed)- -��Q • i w r - . ---______(Owner and/or Contractor) 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__ ------------ -� --------------------------------=------------------------- ------ -------------- ----- ------ DATES -------- - - REVIEWED BY -- ---, --------------- DATE--- -- --------------------------------------------------------------- BUILDING PERMIT ISSUED....... .. "" ------------- DATE------ Al+era}inns and/or recommendations:_--__ - � ------------------------------ ------------------------------------------------------ ------------ -------------------------------- - ------- --------------------------- --------------------------- FINAL INSPECTION BY:---------------------- - Dare. _.1 — '` -� 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 8-51 Revised W-2100