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0 _ APPLICATION I=ORA'SANITATION PERMIT Permit No. ._1�, (Complete in Duplicate) Date Issued _--_{___ 4.- Application is`hereby made to'the San Joaquin•,!vocal Health .District for a permit to construct and install the work herein described. This application is made-iri.compliance..with County Ord inance'No.ti549.. + li (41S JOB ADDRESS AND LOCATIO .......... _ �i Owner's Name QO o - -s/Y p-------- ------- --------: ,Phone Address----------- 3j# �— __ .3 -------------------------------------------------------- Contractor's Name -- " ----------------- ---------------------- ` ------------ ---._. Phone--------------- - ------------- - Installation will serve: Residence]., Apartment House [I Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units;'______ Number of bedrooms'_ Number of baths ___-j__•Lot size _r�-d-_, "'9_ - Water Supply: Public system ❑ Community system ❑ Private ,_Depth to Water Table,5d_ ft. � Character of soil to a depth of 3 feet: Sand Gravel ❑ Sandy Loag�' Clay Loam ❑ Clay [] Adobe ❑ Hardpan ❑ Previous Application Made: Yes,❑ No�New Construction: Yes ❑ No�HA/VA: Yes ❑ No TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or'cesspool permitted if public sewer is available within 200 feet.) Septic Tank: Distance from nearest we11._r Q�__Distance from foundation__ >� . ■� -0----------.Material--------- -----`- - ------ i No. of compartments_.._-------------Size---- ---Liquid depth-�------------------Capacity._ d- -•- Disposal Field: Distance from nearest well. Q_1'_--Distance from foundation._7_5'�_ µ--:Distance-to nearest lot lin Number of fines--/�--- Length,of each line_____1_A0_0-----------Width of trench-- -------------------------- -if 1 Type of filter-'ma' anal__ '_____Depth of filter material_-/0-_r)-------Total length--__-_� --[�------__- ------ Seepage Pit: Distance to nearest well_{"---`--------------Distance from foundation--------------------Distance to nearest lot line___-___._________ Number of pits----------------------Lining material-----------------------Size: Diameter-----------------------.Depth._----------__________ Cesspool: Distance from nearest well___ ..--Distance from foundation__/_6 r.-_..Lining material .__ Size: Diameter_ f Depth--- Liquid Capacity --- ------gals. Privy: Distance from nearest well---------- --------------------------------------Distance from nearest building___________-___________ ❑ Distance to nearest lot line---- ------------------- ------------------ - ---------------------- - r- Remodeling and/or repairing (describe):---------_ --------------------------- ---------------- -------- -------------------------------------------------------------------------------- ------------------------------------------------ --------------------------------------------------------------------------•---•----------------------------•_---------------•-----------•-----•----------------------------------------•---------------------------------- --------- --- - -- --------------------------- ---------------------------- --------------------------------------------------------------------------------------------------------------------- -. I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin Ccs tv 0, ordinances, State laws, and rules and regulations,of the San Joaquin Local Health District. (J`{ (Signed} 2A- ............................................................. ------(Owner and/or Contractor) l By:------------ -----------------------------------`1 -------------------- - - 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------------------------------------- DATE -------------------------------------------------- - R1 VIEWED BY /� � 1 DATE--- - ------- ------ UILDING PERMIT ISSUED I .--DATE------- ---- --------- ------------- ------ Alterations and or reco )men ations:_______.-.__ _ E�Z ------ - - - ----------------------------------- = -� - - - ---. --------------- --- �, - ----Iv -; �- __ n --------------•--- - FINAL INSPECTION BY----------------------------- ------------- Date.--------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Sfreet $14 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California ES-9-2M , Revised 1.57 F.RCO.