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A- 0 APPLICATION FOR SANITATION PERMIT (Complete in Duplicate) e2 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 Ica- Ordinance jNo. 49. JOBADDRESS AN OCATION---5.) Ica------- -- --- -----------------------------------------------------------------4*---------------- Owner's Name---- - - / r ----------------------------------------------------------------- Phone---------- Address-=- tf.3----- _ Contractor's Name Phone--- -- -- Installation will serve: Residence Apartment House ❑ Commercial .9 Trailer Court t el ❑ Other ❑ Number of living units: 11 Number of bedrooms C3 ,Number of baths [7 Lot size------6-b_-A...(10------------------------- Water Supply: Public system 04 Community system ❑ Private ❑ Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe X1, Hardpan ❑ \' TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) ` Septic Tank: Distance from nearest well_________________Distance from foundation--------------------Material_____---•:--•__---_-__-•_-___----------__-.- ❑ No. of compartments--------------------------Capacity-----------------------Size--------------------------------Liquid depth-------------------------- ,Cesspool: Distance from nearest well-----------------Distance from foundation....................Lining material_-__--_-_-__ _-____._ __.__.._. p Size: Diameter--------------------------------------Depth--------------------------------------------------- Privy: Distance from nearest well-------------------------------------------------Distance from nearest building___---_--__•_____--_•-_-___•-__-----__•--- ❑ Distance to nearest lot line________________________________________________ Seepage Pit: Distance to nearest well---------------------_Distance from foundation--------------------Distance to nearest lot line-_--__.---__---_. ❑ Number of pits----------------------Lining material.......................Size: Diameter........................Depth-------------------........ -__--- Disposal Field: Distance from nearest well.... ___._.Distance from foundation___-_-/j--------Distance to nearest lot line-.---z--------- Number of lines_________ ________________ ______Length of each line------->tQ--------------Width of trench-___•J tx4 �_ Type of filter materia ___Depth of filter materia___3____6i---------- Remodeling and/or repairing (describe) " • ►--Ilk-------- . ------.-- ----------•------------------------ -------------------•-----------------------------------------------------•---------------------------------------------------------------------------------- ------------•--------•----------------•---------------- I hereby,,c ify that I have prepared this apalication and that the work will be done in accordance with San Joaquin County ordinances, St Taws, and and regulations of the San Joaquin Local Health District. (Signed) ------------------------------------------------------------------------------------(0,4ner and/or Contractor) By:-------------------------------------------- --------------------------------------------------------------------------------------(Title)----------------------------------------------------- (Plot plans, showing size of lot, location of system in relation to wells, buildings, etc., must be filed with this application). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY AV ----------------------------------------------- DATE __ .. .. REVIEWEDBY--------------- ---- ---------- -------------------------------- DATE BUILDINGPERMIT ISSUED---------------•-------------------------------------------------------------------------------------- DATE----•-------------- Alterationsand/or recommendations-------------------------------------------------------------------------------------------------------------------------------------- --------------------•--------------------------------------------------------------------------------------------------------------------------------•-------------------................................................... -------------------------•------------------------------------------------•--------------------------------------------------------------------------------------------------------------------------------------------- ----------•---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- f/ ,/ 7 / PERMIT No.. _ 'T=_6_ ISSUED...... ------------(Date) FINAL INSPECTION BY:_-_... ..__ r ------------------------- -------------- ___..._____._-_-.-_ Date-------------�� __j---, „ ----------- ---- ----•- SAN JOAQUIN LOCAL HEALTH DISTRICT uth American Street -' " Stockton, Cafifornia ES-9-2 M 9-50 W-1639 r � *