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f IVY, 3 APPLICATION FOR- SANITATION, PERMIT Permit No 3 3 0 (Complete in Duplicate) Date Issued7__ , 0— A licafion is hereby by made to the San Joaquin Local Health'District for a permit to construct and install the work here This application is made in compliance with County Ordinance'No.__ 5described. !:�'v 9 in descr JOB ADDRESS AND LOCATION ___--- -- -_,r -- ----- -------- ----------------------------------------------------------------------------------- Owner's ---------------------------------- --------------------------------------------- Owner's Name---------- - -- -W _� -------------------------------- - � 3 � .,,� one-------------- ------------------- - Address--------------- -------------------- ----"- ---------------- ----- --- rr j -------------I------------------------------------------------------(G-----I�l-------- Contractor's Name__- ---------- _ d_- Phone_- �_ - ------------- -- -------------- -- - ----------------------------------------- Installation will serve: Residence Apartment House [] Commercial ❑ Trailer Court ❑ Motel Other ❑ Number of living units: Number of.bedrooms _/"_ Number of baths _/_- Lot size ---------7o Water Supply: Public system ❑ Community system ❑ Private ❑ Depth to Water Table -------- ft. Character of soil to a depth of 3 feet: Sand ❑ Grave€ ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe ❑ Hardpan E❑ Previous Application Made: Yes p •No ❑ New Construction: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: f (No septic tank or cesspool permitted if public s6wer is available within 200 feet.) W -Septic.T Distance from nearest welL_�G____"Distance fr oun ation_Xo--------Material_-&---- _ No. of dompartments-____ ---"_Size_3-X&'AAX /- Liquid depth-- ,- Capacity--kQw------- !y Disposal Field: Distance from nearest well S_._'Di'stance from foundation----X - Distance to nearest 1 line__ -------- Number of lines_.,____ iLength of each 1.ine_010'!( _____-Width of trench_ 2Type of filter materiai____S � r--------- ------------- Depth of filter material_��_-_--------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-----------------DrDtan'c'e-from foundation ___ ____.Linin ;,maferial-_____________ ❑ Size. Diameter__ Depfih== W_W =- L-iquid Capacit}7- - ---------------------gal' ri Distance from nearest well _ Distance lfrom'riearesf`buildin s.� . 9 ----------------------------------- ----------------------Distance to nearest lot line-------------- -------- - -- -------------------------------------------------------------------- -- Remodeling and/or repairing (describe)________________"___. --- --- --------- ------------- f ---------------------------=------- ------------------------------------------- ----------------------------------------- =_ - -=- ----- -- ------------ -"--- -- --- ------ ---------------- ------ I hereby certify that I have prepared this application and.that the work will be done in accordance with San Joaquin County ordinances, State la , and les and're i ions", :acal Health #rict.(Signed)-------� - • -------------- - ------ ----- --ti (O d/or ntractor) By = -----• r (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be'place on reverse side). I. FOR DEPARTMENT USE ONLY + 7 "�- APPLICATION ACCEPTED BY--_____--____/ _ ,�_-_- ' REVIEWED BY- ------------ DATE- �---- 1 ' -------------------------------------------------------- - ----------------------- DATE_-- / u ----------------------------------=------------ BUILDING PERMIT ISSUED--------------------------------------------------------------- DATE- ----------'_#------------- Alterations and/or recommendations:---------- --------------------------------------------------------- '----------------------------------- - --------------------------------------------------- - - --------------- •------------------------------= ------------------------ ---------------------------------- , -------------- ------------------------------------------------=--------------=- FINAL INSPECTION BY---------------- - -- ------ Date 2 ------------------------------ SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Street 814 North "C" Street 1 Stockton, California Lodi, California Manteca, California Tracy, California ES-9-2M 8-51 Revised`W-2100