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APPLICATION FOR SANITATION PERMIT Permit No. rN (Complete in Duplicate) Date Issued Application is hereby made to the Son Joaquin Local Heaith District for a permit to construct and, install the work herein described. This application is made in compliance with County Ordinance No. 5,4,9. - - -- - -------- ---------• ------------- JOB ADDRESS AN LOCATION_----�Ko_) -- -- ----- ---- L--- ----- Owner's Name_ --- ---- ---------- ---- --------A ------- Contractor's -- --- -------------- Phone----------------------------------- Address ------------------------- ------------------- _ ------- - ------- --- --- Phone----------------------------------- ----------------------- ----------- -- Installation will serve: Residence Apartment House [-I Commercial E] Trailer Court El Motel El Other E] Number of living units: Number of bedrooms _lp__ Number of baths __1____ Lot size _____________________ Water Supply: Public system ❑ Community system E] Private 14_,,Depfh to Water Table � ft. f Character of soil to a depth of 3 feet: Sand E] Gravel E] Sandy Loam� Clay Loam El Clay El Adobe El Hardpan 0 Previous Application Made: Yesie No [:] New Construction: Yes� No E] FHA/VA: Yes El No El TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or'cesspool permitted if public sewer is available within 200 feet.) Septic Tank; Distance from nearest well---CYI� Distance f f d . n Material---- - ------------------------------ -- ------ from "'4�%Lo -------- --- No. of compartments Size Liquid depth_,___y------ ---------Capacity_ 4,61 ------ --- 11 - --- ------ Disposal Field: Distance from nearest well_ ( -------Distance from foundation- +a :d----------Dis n`ce to nearest lot line-- Number of lines--------- --------Length of each line------- ------Width of trench----- ---________-____ Type of filter material___ -- L__-------Depth of filter material--- --------____Total length--------- ------------------------------- e- Seepage Pit: Distance to nearest ----------Distance from founclaf ion......p?,,0_Disfance to nearest lot I;ne---tl--------- Depth...... Number of pits---------/----------Lining material_,� I Cesspool: Distance from nearest well_______________Distance from foundatio7 --------------Lining material______________________________________ ❑ aterial-------------------------------------- EJ Size: Diameter-------------------------- ----------Depth------------------------------ ---------------------Liquid Capacity----------------------------gals. Privy: Distance from nearest well--------------------------------- ---------------Distance from nearest building______-- -_____ ` ❑ Distance uilding------ ---------------------------------- Distanceto nearest lot line--------------------------------------------------------------------------------------------------------------- ------------------------ _*_� /:,a /b , �a44a ----4 --�!.. Rem and' e'pa i in escribe):-- -,------- ,p)deling 9 --------------------------- _-N--•-----------------------------------/----------------------------- 0 ll ....�f------------------------------- ------------------------------- ------ ------------------------------------------------------------------------------------------------ ---------------------------------- -------------------I------------------------------------------------ --------------------- ------------------------------------------------------------------ ------ -------------------------------- --------------- I k I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State law;, and rules and regulations of the San Joaquin Local He'olfh District. -------------- (Signed" • -------------------------------- --------------------- Ar--------(Owner and/or gConfractor) BY:----•------------------------------------------------------------------------------------------------------------------------------jif le)------------------------------------------------------------ -- (Plot plan, showing site of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). I FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED B�------------------- --------------- - -----------I----------------- CE --------- ----- - DATE-------------------------- - - -------------- REVIEWED BY-----------i--,L----------I - ------- ------------- ------ - ----------------------------- ------------------- --- _-4 DATE- ------- -- ----- BUILDINGPERMIT ISSUED---- --- -- - ----- - - --------------------- --------- DATE--------- ----------------------------------------- Alterations and/pr rec*o en tio'ns:-- --------- -- - --- --------- ------- --------- ------------------- --- ------------------------------ --------- -- ---------------------------- --- -- - --- --- - ----- -- -- -------- ------------ ---------- 0-- -- ------ ----------- - ------------- -- ----------- ---------------------------------- - ------------- --------------------------------- FINAL INSPECTION BY:.------ D ---- -- -------- SAN JO QUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Street 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California ES-9-2M Revised 1.57 F,P-CO.