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, �t0 APPLICATION 4F0 `SANITATI N PERMIT Per mit No.' y63 ..................."••__ (Complete in�iTuplicate) TM "�! Date Issued Application is hereby made"to the San{J qurn Lodal Health District fora permit to construct and install the work herein described. This application is made in complian ith County_OrdinanclO,f5g�g.� JOB ADDRESS A LOCAT N_-"" - Owner S Na-e___ __ -- -- � w _ """_"J_"__-• --t ----- Phone� - ! - 1 ------------- I, - ---- -- - ----------- -----------•---------"-----•----------Contractor's: Name - ----- ------ •-------- Phone Installation will serve: Residence Apartment-l ❑ ouse arnerc m (a[ ❑ Trailer Court. 1[J O'her [ �" r r Number of living'units: __�____ Number of bedrooms __ " Number aths -_f-____ Lot sized i Water Supply:-Publics stem " """""----------------- y ❑ Community system El.' Privy#e Depth'to Water Table __..____ ft: Character of soil to a depthlof 3 feet:?.Sand Gravel ❑ Sandy Loam Cla Loarrr Clay Y ❑ y ❑ Adobe Hardpan ❑ pp ade: Yes ❑ No IVew ..- — ruct€on:. Previous Application M TYPE OF INSTALLATION AND SPECIFICATIONS: �~ (No septic tank br`cesspool permitted if pubic sewer is available within'200 feet) r Septic Tank: Distance from nearesr wel V ` istance from foundation_/- " Material-- . ------ _-- _ l-1 No�.of compartments__-- - -•-,��.+ x_'Siz �-_'•_-�-��_�� Li -"-- i. f ;, quijd}�lie tkm------ --------------Capacity.--- Q Dispose field.: Distance .from nearest we __• "__---____Distance from foundation�11_`+"! t .. j f- - --- i'stance to nearest Ilot line�__e5�f.Los/ umber of lines__," ____ ____ _ Length of each line__-____. t=_.-.Width of trench______ i, " - ------ --- r ,r -------- Type of filter mater k { "' -depth of filter material_._.-___I- ._ --- - -----Total length------------�--b-0-_------ p.g a#J_ See a a Pit: Distace..to nearist "# ::-"---'__Distance from foundation_____:.-___•-______.Distance to nearest lot line_________ ❑ Numb'er of pits.......................L Hing 'material-----------------------Size: Diameter --- --- --------Depth I ! ---- Cesspool: Distance from nearest ry it _______________D&a'hce from'fourid�fiion -_ - .e,l „ Lming maFerial_"' . ❑ Size: Diameter - -- ------- ------ --`-Depth------- t :- --------------------------Liquid Capacity------------------ ---------gals. Privy: Distance from nearest welf__.__" .� ______________________________Distance from nearest buildin € _ 9 -------------------------------------- nearest Distance to lot line___________ ____ __ - Rom eiing and/ r repa44 g�d'e�cribe� =----------------- ------------------ = ' ^^ --- 6- -------------- --- ---------------•----------------------------------------I----------- - _ �I hereb certif that i have �. - - • - -- -------------•-------•-----•---------------------------------------------------------- Y y prepared this-eapplica+ion and that work-will be done in accordance with San Joaquin County ordinances, 5ta'a laws, and rules wand regy1atiops of the San Joaquin Local Health District. Si ned ( 9 ) / • -------------- . F i ' [Owner and/or Contractor) ` - ------------ -------(Title}----------------------------------------------- (Plot plan, showing size of lot, location of system in.relatiCnfo wells, buildings, etc., can be placed on reverse side). ; FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED B <. -- - - = DATES-__.------ --- ------------ - - -----------•----•--- REVIEWED 13Y ---------- � y -= ; -------- - J; BUILDING PERMIT ISSUED__-. )_ DATE__--- Alterations and/or recommendionsi'`-----,-----"-__-- i +1 . : .� DATE ---- -- -------= --------------- � - -. ---- '------------------------- ------- =a- --5- `-----_ :::.....::.:....... -----------•---------------------------------- --- -----------------------------_________ FINAL INSPECTION' --"----- .. Date--_.----•_--__-- `-' r ------------- ---------------•----------. SAN JOA UIN LOCAL CAL HEALTH DISTRICT I 130 South American Street 300 West Oak Street 132 Sycamore Street 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy. California f ES-9-2M , Revised 1.57 F.P.CC). {