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1 lr APPLICATION F(__'_�SANITATION PERMIT Permit No: _1?0._.....__... (Compfete'in Duplicate) Date Issued ___�____ -k.... 3- Applica*ion is hereby made to the San Joaquin Local Health District for a permit to construct.and install th�ew�ork In e n described. This applicationiss made.in compliance� with County Ordinan No. 9. JOB ADDRESS AN ATION_. -. Owner's Name ------- - _ -------- -- --- --------- --- P ne-- ---- -- -- ----- - - 7 Address ` .• _ ----------------------------------------------------- Contractor's Nam ------------ _ ---- ••----- Phone .2� Installation will serve: Residence ❑ Ap rtment House ❑ Commercial ❑ Trailer Court ❑ Motel E] OOt_her Number of living units: __-----_ Number of bedrooms____ Number of baths �_ Lot size _, ��C ------------------------------ Water ________________________Water Supply: Public system ❑ Community system ❑ Privateg Depth to Water Table. t. Character of soil to a depth of 3 feet: }Sand E] Gravel ❑ Sandy Loam E] Clay Loam ❑ Clay ❑ Adobe Hardpan ❑ Previous Application Made: Yes ❑ No New Construction: Ye No ❑ / i TYPE OF INSTALLATION.AND SPECIFICATIONS: W �•�„_ „ (No septic tank or cesspool permitted if,public sewer is available within 200 feet.) Septic Tank: Distance from nearest well_______________Distd-nce from foundation_-.____.__- ____-.Material______________________________---_--_________-_. No, of.compartments--,_____- -__Size___________ t __Liquid de th-----------------_--------Capacity kDisposal veld: Distance from nearest well_________________Distance from foundation--------------------Distance to nearest lot line----------------- _ r Number of lines-----------------------------------Length of each line---------------------------.-.Width of trench---------------------------- ---- Type of filter material--------------------- --Depth of filter maferial---------------- ;,----Total length-------•.__----------:-------------------- j Seepage Pit: Distance to nearest well_�__f�_________Distance fr fa dation_ �_________-Distpce to nearest lot line_______________._ Dt Number of its- ------Lining material'- - -• -----a -size: Diameter---- -----------------Depth--------- ------------------ Cesspool: ----:---------Cesspool: Distance from nearest well----------------=Distance froff foundation---------------------Lining material_----_-_ `--r:''-------- ❑ Size: Diameter-------------------------- -----------Depth ----------------:-----:----Liquid Capacity----------------------------gals. O Privy:, Distance from nearest well ___,.___________________________ ____-----Distance from nearest building-------------.______--_- ❑ Distance to nearest,rlot line " -- ------`�-.- _- ,. ,,, --------------------------------- Remodeling and/or repai ng (describe: l r • ---------- 7 ••---- - •----------•-•---- - -----•-------- - ------- --------------------- -- - •----•---•-••---------- ----- --------• ••------•-•---------•--------- ------- -•-----------------------------------•••------------------------•-------------------------------------------------------- I hereby certify that I have prepared this app ication and That the.work will-be done in accordance with San Joaquin County ordinances, S laws, d r les and regulations of the San Joaquin Local Health District. (Signed)----- ------- = --------------------------------------------- Owner and/or Contractor By: --------------------- Title - -------------------: ----------------- - (Plot plan, showing size o lot, location of system in relation to wells, buildings, etc., can be placed o averse side). ' FOR DEPARTMENT USE ONLY APPLICATION•ACCEPTED BY------------ ------ ------ -- - -------------------- -----------.---------------------------- DATE--- -- ____ ___ _______ ___________ �____-_______F___---____-______________ DATE------ BUILDING PERMIT ISSUED ------------------------- DATE--------- ----------_ ----------------------•------- Alterations and/or recommendations:-•--r----- --- --- ---- -------------------------•-----------------------------•-------------------- ---------- ---•-------------------•------------- T----- ---- --- --- --------------------------------------------------------------- -. Y r ` FINAL INSPECTION Date__.:--.--_�_ r-S SAN JOAQUIN LOCAL HEALTH DISTRICT 130 Soufh American Street 300 West Oak Street 132 Sycamore Street 814 North "C" Street A ' Stockton, California Lodi, California Manteca, California Tracy, California I , I ES-T-9-2M Revised W-2100