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APPLICATION FOR -ANITATION PERMIT Permit No. (Complete in Duplicate) / Date Issued _Z/ 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 ,County Ordinance No. 54.9. ' JOB ADDRESS A LOCATIO __p__.--r------- = ---------- Owner's Name_ Ph _ '1_ (� one Address----(r,3_j--------- Contractor's Name- + -- -------------------- Phone. -` Installation will serve: Residence ® Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel_❑ Other ❑ Number of living units: __I_.__ Number of bedrooms ___A_ Number of baths __ ____ Lot siz Y --------------------- Water Supply: Public system Community system ❑ Private ❑ Depth to Water Table : 0__ ft. `ti�� Character of soil to a depth of 3 feat: Sand ❑ Gravel ❑ Sandy Loam [] Clay Loam ❑ Clay [] Adobe [B Hardpan ❑ f Previous Application Made: Yes ❑i No W New Construction: Yes No ❑ FHA/VA: Yes ❑ No TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or'cesspool permifted if public sewer is available within 200 feet.) Septic Tank: Distance from nearest well-----------------Distance from foundation___________________Material____._______________- ______..___________- No. of compartments---------- --------- -----Size---------------•----------------Liquid depth--------------------------Capacity tzpo4r,,,�zid: Distance from nearest well_________________Distance from foundation--------------------Distance to nearest lot line________________ Number of lines-----------------------------------Length of each line------------------------------Width of trench---------_------------------ ----- Type of filter material------------------------- of filter material-----------------------Total length--------------------------_______________ Seepage Pit: Dis#ante to nearest well__ _ l3istance f m foundation_ ______ Qist�e to nearest lot line_ =- Number of fts.____.___ - p F �___________Lining material___ Qia ter�V.11 ` ,<e�c�Dep p-`��- •-- -- -'-- Cesspool: Distance from nearest well_________________Distance from foundation--------------------Lining materia--- ____.______._______ ❑ Size: Diameter--!----------------------------------------------------Depth_----------------------------------_- __ -Liquid Capacity Privy: Distance from nearest well------------___----------------------------------Distance from nearest building---------------------------------------__ T1 ❑ Distance to nearest lot line = = emodeling and/o r p 'rte {des--,_be):- ' _ _ ------ -_-_- - - - --- ^'1 - !\ --------------------_--------------- ------------------ I hereby certify that I have prepared this application and fhat the work will be done in accordance with San Joaquin County ordinances, State laws, and rules and regulations of the San Joaquin Local Health District. (Signed)-- ----- ---- -- ----- - -- -- - -- ---- r (Owner and/or Contractor) By:- -/Ya '----------------------------------- (Plof plan, owing si lot, ocation of system in rea+ion to wells, buildings, efc., can be placed on revere side). L OR DEPARTMENT USE ONLY APPLICATION.ACCEPTED BY--------- ----------- ---------- ---- ------- ------ -------------------------------- DATE------- -------- ---- REVIEWED BY--------------------------------- - DATE �� BUILDING PERMIT ISSUED -- ---------------------------------------------------_- DATE------------- Alterations and/or recommendations-------- ---------- - A---------------------- - ---------------------------------------- ---,-�-� ---------T--- Y-- : -------- d , �� R ------------------------------------------------ � e �Z-------- �O/ 1=5�e FINAL INSPECTION BY:_------ ---'- -------------------- Date---- ------ - - --' ----------------- - ----------------- Iw SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street j 132 Sycamore Street 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California ES-9-2M , Revise(i 1-57 F-P.CO.