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APPLI ION FOR SANITATION PERMIT Permit No. _.__. .. a_... k (Complete in Duplicate) �L z Date Issued - S -- Application is hereby m "e'l'k a San Joaquin Local Health District for a permit to construct and install the work hereiry described. This application is made fid mlpliaAnce with County Ordinance No. 54/9. j `/7{ 2S`19 V0—n v JOB ADDRESS.AND OCATIO �/1�r = �rt� { < --------- ------------------ --------- -- --------------------- --- - - ------ -- Phone----------------------------------- Owners Name_____ ,__M Address--------- ------- 7 - Ip . — s Contractor's Name-------------------------- - ----- --------------------- --------- Phone------------------------- Installation will serve: Residence Ap ment House []_ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units:°____ Number of bedrooms ---:f� Number of-baths ---J--- Lot size --------- _________________ Water Supply: Public system, ❑ Community system ❑ Private 0 Depth to Water Table 10--- ft_ Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ ClayX Adobe❑ Hardpan ❑ Previous Application Made: Yes ❑ No [ New Construction: Yes �" No E] TYPE OF INSTALLATION AND SPECIFICATIONS: 1 (No septic tank or cesspool permitted if public sewer is available within 200 feet.) II Septic Tank: Distance from nearest well---- --_Distance from foundation-------l-i--_.-Mev -------- Noof compartments depth----------- ---------- --Capacity.... --�_ ----- Dispo al Field: Distance from nearest well____ ._Distance from foundation---- _-----Distance to nearest lot line_-_-- ber of lines--------------/-----.- -----------Length'of each line------ ..._..-,Width of trench-------.rte__---�__ --------- Type ter mater.ial----ts' 2A- epth of�filter material-----/F---- --_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--------------------Lining material--_ --._.------.-.-_-------- _0 _ Size. Diameter-----------------, -- --Depth------------------------------------------------------Liquid Capacity----------------------------gals. f I Privy: Distance from nearest well-------------------------------------------------Distance from nearest building--------------------------------------- Distance _-_--_----_-.-_----__-._._Distance i` nearest.lot line----------------------------------�-------�--yy---------------------------------- ------- -------- -------------------------------------*�" + �7 Remo elin and/or re air:n (describe):-- ---- ---- -------A -.01-LA ------------ -s- -------- g I Pg ----f p L� �f IV � ems+-�"� .►e. F_ r + .' .!5� — •• =��' _-- ' � �� -- ---- I hereby certif thahe've prepared this application and that the work will be done in accordance with San Joaquin County ordinances, Stat' s a rules and regulations of the San Joaquin Local'Health District t I (Si ned __ 4 ,---' g =--------�--- -- ----- -- -- -- � --- - - - -------------------------,-------- ------------------------;-- -(Owner and/or Contractors i By:----------------------------- -'------------------------------------------------------------------------------------------------(Titlel_-i = --------------------------- - --------- -----„ [Piot plan, showing size of lot location of system in relation to wells, buildings, etc., can be placed on reverse side]. p FOR DEPARTMENT USE ONLY 'k APPLICATION ACCEPTED BY------------------`-1-•------------- -------- ------- - ------------------------------- DATE------------------ —� REVIEWED BY `----------- - DATE v� BUILDING PERMIT ISSUED ��------------------- ------- DATE ` ------------------- ------------------ --------------------- and/or recommendations:---------------------------------------------------------------------------- ------------- ---------------------------------------------- ------ i i! 1 # N------------ --------------------------------------- ------------------------------------------------ il ---------------------------------------- -�;------------ - FINAL INSPECTION BY:. Date------------ —a � ---------------- �I SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street ;' 300 West Oak Street 132 Sycamore Street 814 North "C" Street Stockton, California ir Lodi, California Manteca, California Tracy, California ES-9-2M 10-52 Revised W-2100 4