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li APPLICATION FOR SANITATION PERMIT Permit 11o. 0V... in Duplicate) / (Complete Date Issued ---la_ 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 No. 549. JOB ADDRESS AND LOCATION------- ------ ____________ ----------------------------------------- Owner'sName--------------- ---------------------�tpp_C�_'< ---------- Lj-'�L�C1�� ------ AddreAddress ss-----------------------------------I---------------- a., _:__ �1 �1 ? .. = -------------- --------------------------•- i Name----------1---------------•- .H '" ''.f �� c-- Phone---- Contractor's -- ------------------ - ---------- -- ------ Installation will serve: Residence 1,5� Apartment House ❑ Commercial ❑ Trailer,Court ❑ Motel ❑ Other ❑ Number of living units: __ __ Number of bedrooms ___ Number of baths Lot size ._-_------ __ ____ ®_Q'__.._-_____._ Water Supply: Public system [k Community system � Private ❑ D.epth b ater Table ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam.❑ Clay Loam ❑ Clay ❑ . Adobe Hardpan ❑ Previous Application Made: Yes ❑ No H New Construction: Yes ❑ -No ® S�elv TYPE OF INSTALLATION AND SPECIFICATIONS: -- GcTs o (No septic tank or cesspool permitted if public sewer is available within 200 feet.) — Se is Tank: Distance from nearest well_________________Distance from foundation-------------------MateriaL_____.________.__----------------_-_---------.'4V No. of compartments--------------------- ----Size----•-•-------------------------Liquid depth--------------------------Capacity-----------------------XV iso sal Field'[Distance from nearest well-----------.-----Distance from foundation--------------------Distance to nearest lot line_______._________ Number o-i lines-----------•-----------------------Length of each line--------------=- -------Width of trench.----------------------------_-__-- ` Type of filter material----___�-,-„--------._ Depth feria---- -_'__:_r_ Total lengl+h------------------------------------�(y Seepage•Pit: Distance to nearest we _ __ ' tan fr foundat n----- --------Distance to nearest lot line____ Number of pits----�---------- Lining mterm__-Siz Dia eter__-�� p �Q! --------� ` x' - - De to Cesspool: Distance from nearest well_________________ _ tante from found ._------- Lining material--_... _______-----------.--------_. ❑ Size:'Diameter Dept Liquid Capacity gals. Privy: Distance from nearest well----------_--------------------------------------Distance from nearest building-------:.------.-------------------- -__ ❑ Distance to nearest lot line ----------- ------------------------------------------------------------------------------------------- ---------------- ---- g / (describe): � -n Remodelin and or repairing 1 '� ``'E� �u-. ` =�`-= =J �'= �----------- -----------------•-•--....._. `•— •- ---------- --------------------------------------------------------•----------- f ---------------------------------------------------•-------------------------------•------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ I ----- I hereby certify that I have prepared this-Application and,fhat�fhe work will-.be&46 m accordance with San Joaquin County ordinances, State laws, and rules and regulations of t e San Joaquin Local Health District. . (Signed)------- ------- ------ � � _L --- ----------------------- -- ----(taw anzl�=.C_ontractor). =”` = ------------(TitleS-!�_�"2-z -f. - .__. Y� - { ) [Plot plan, show' g ize of 10. locatio of system in relation to wells, buildings, etc., can be placed on reverse side). j; v FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY---------------------------------------------- - -- DATE--------- -- -- -----: REVIEWED BY5----------- ----------•------------- ••---•-- DATE .' BUILDING PERMIT ISSUED------------------------------ --------•------- - ---------.- DATE-------------- Alterationsand/or recommendations:--- ---------------------------------- ---------------------------------------- ----------------------------- ------------------------------ -•----------- ------------------------------------------ ------------------- ------------------------------------------------------------------------------------------•--------------------------------------- j -----------------------•-----------------------------------------//°��------------------------ --------------------------- FINAL ------------------------- 7 FINAL INSPECTION BYi---------------Y-_-_1----- '� --- ---------- 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 10-52 Revised W-2100