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t. APPLICATION FOR SANITATION PERMIT Permit No. ___ _7_f--------- 'A ----__-_' } (Complete in Duplicate) Date Issued 7.6 I.5 1 I 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 wifj County Ordinance No. y1749. JOB ADDRESS AN LOCA N------ I Owner's Name---------- - -- --------- ---- - ----------- - -- ------ Phone------------------------------ , ,,, 1 ------------------------------ ----------- Address------------------ •---------� - ---------W�- �--,.1-�f"=�--'----- --------------- ---------- -- -------------------------------------- � d-- --�i- . ----- Installation Name----____ d------ - ---------- Phone- ------- --------- Installation will serve: Residence ❑ Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ElOther [INumber of living units: f __ umber of bedrooms ,A-- Number of baths __ -- Lot size -------- "�__ "__ _d__ ______________ Water Supply: Public system [Community system ElPrivate E] Depth to Water Table ft. Character of soil to a depth of 3 fee+: Sand Gravel E] Sandy Loam E] Clay Loam E] -Clay E] Adobe Hardpan Previous Application Made: Yes E] No EV New Construction: Yes Flo ❑ ` PE OF INSTALLATION AND SPECIFICATIONS: TY (No septic tank or cesspool permitted if public sewer is available within 200 feet.) W► Septic Tank: Distance from nearest we{i_________________Distance from foundation--------------------Material-------------------------------------------------- o. -------_--___-_----__----_;--_ ----.o. of compartments-------------- ize--------------------------------Liquid depth--------------------------Capacity----------------------- �� /� _Distance to nearest lot Iine._cs---_-_--- Dis "osal -eld. Distance from nearest welll�4r_�___._Distance from foundation-_-1,49 Number of lines____ ______- Length of each line____�..�-_._ j� Width of trench---- - r_-______-------_- of filter material________ _,'- f De th of filter material____�_D_-____ _ Total length_____ .__ ----------------------- Type c.�t � _ ps Seepage Pit: Distance to nearest weIIdQWW; Distance fou ation---- /---_--Di' f ce to nearest lot line-'k5 Number of pits____ Lining material Diameter_____?..._.___ p �I-J�---_- - -----.De Depth ------------ Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material--------------.--------------.-_--_-_. ❑ Size: Diameter-------------------------------------Depth---------------------------------------------------_Liquid Capacity-----------------------------gals. =, Distance from nearest buildin .F Privy: Distance from nearest well---------- ------------------------ g--------------------------- ------------ ❑ Distance to nearest lot line-------- ------- ------- --------------------------------------------------------------- Remodeling and/or repairing (describe) -- --------- '-- -----------------------------------------------------•------- ... = ------------ ----------- i ----------------------- ---------------------------------------------------------------------- ----- ----------------------------------------------------------------------------------------------------- ------- - I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State laws, and rules a d regulations of he San Joaquin L cal Health District. r� - {Signed) f J A----- --- --- - ---- --- --- - --- -- F ------------------------ (Ow r and/o ontractor) ;.. ......(Ti+le-----60 --------------- (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-_C_;-- --------------- DATE -c-------------------------------------------------- REVIEWEDBY-------------------------------- �--------------------------------------------------------------------------- DATE------- --------------------------------•----------- 1 BUILDING PERMIT ISSUED------------------------------------------------------------------------------------------------------ DATE------------------ ----------------------------------------- Alterationsand/or recommendations:------------------ --------------------------------------------------------------------------------•---------------------------------------------------------- ------------- - -•------------------------- - ---------------------------------------------------------------------------------------------------------------;--------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ -------------------•------------------------------------------------------------------=--------------------------------------------------------------------------------------------------------------------------------------- ----------- - - ---------------------------- ---------------- ---•------------------------------------ I FINAL INSPECTION BY:---------- { Date------------ I_ -------- SAN JOAQUIN LOCAL HEALTH DISTRICT K 130 South American Street 300 West Oak Street 132 Sycamore Street 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California i I LS-9-2M 8-51 Revised W-2100 F �