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APPLICATION FOR SANITATION PERMIT Permit No. J3_.b Y (Complete in Duplicate) Date Issued Application is hereby made to the San Joaquin Local Health District for a permit to construct n instal the wor herei d,eiscribe This application is made in compliance-with Count Ordinance No. 549. , �, +� JOB ADDRESS A LOCA IONtf_-- 1 _ --- --- -- ------ --- ,. a A Owner's Nam 1 ------------- ...1._ � Phone_ _hl-- Address........T-� -- ---- ..! !` -------------•----------------•------------------- Contractor's Name--- -------------------------- ----••---------------------------------------------------------------------•--------------...._. Phone---•-- •----------------------- Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court Mot0 Of he[ ❑ Number cf living units: ___ __ umber of bedrooms Z Number of baths -1----- Lot size _ _:�-l/____________________------ Water Supply: Public system M Community system-❑- private ❑ `Depth'to Water Table--------- __.___ ft_ - -" — Character of soil to a depth of 3 feet: Sand [-] Gravel ❑ Sandy Lo;'No Clay Loam ❑ Clay E] Adobe 2 /HardpanE]Previous Application Made: Yes E] No IR/ New Construction: Yes ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted.if ,ublic sew r is available within 240 fee .) I S Septic ank: Distance from nearest wel r�A�stancp fro ffoun tion'l_A ---- at�ri I No. of compartments----_---___14+ iz _+ _ ` ----Liquid dlepfh --- - -------------Capacity----_ Q ----- , �yy I Dispos I�Field: Distance fio_m nearest 1 11 ! istance from foundation_I- _____ isfance to nearest I t 11 e fes __.____ [V Number of lines___._____ �.L ength of each tp__(9--14t-.Width of trench-__. _ ___�`!_� T_. 0-1---------------- Number of filter mater ,,rDepth of filter material___.___._ �- Total length--------- _/�__--------------------- C Seepage Pit:.. Distance to nearest well____...____---_.A_TDistence from foundation______ Distance to nearest lot line_________________ ❑ Number of pits------------ Lining>material------ -------------- Size: Diameter------------------- ---Depth--------- - -----------•--------- � Cesspool: Distance from nearest well_-_______ �Distance from foundation___-----------------Lining m�ate-rial---------------- 0 __-____.___ ❑ Size: Diameter--- Depth _ = a__l_s_..: C-- ------------- apacity- ----------------- ' Privy: Distance from nearest welld Distance from nearest building__ ______.__ ❑_.. ' Qistance to nearest lot line----------- ='--------------•---------------- •----------------------•- --------------- --------------- ----------------------- i Ramo a ing and/ repairi (describ r- --------- -----------ti---------------------------------------•--------------- /'yvij �_ - -------------------------------------------------------------------------------------- --------------------- ---- --------------------------------------------------------- -------------------------------------------------------------------------------------------------------- ------------------------------- -----------------------------------•-----------------------------------------------------•-• ----------------------------------------•------------------------------------------ I hereby certify that I have prepared this al plicafion and that the work-will be done in accordance with San Joaquin County ordinances, State laws, and rules and regulations of the SanJoaquinLocal Health District. (Signed)--------- eZ,, C. •--------- --------------------------I------------------------------------------.-(Owner and/or Contractor) By:.- ------------------- --------------------`------------------------(Title)------------------------------------------- - ------------------ (Plot plan, showing size-of lot, location of sys1em in relation to wells, buildings, etc., can be placed on reverse side). .FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY DATE�---------- ---------------------------------------- ----- -------------------------------------------------------------------------- REVIEWED BY------------------------ 1 = DATE__. BUILDINGPERMIT ISSUED ----------------------------------------------------------•--- -•---------------------- DATE-.------- ---------------------- Alterations and/or recommendations:------------___--------- _ _ -- --------------•-------------------------------------•------ i - - ------------- -------- d --------------------------------------------------- FINAL INSPECTION BY:... ------------------------------------ Date------C /. /.--- s Y 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 10-52 Revised W-2100