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1 APPLICATION FOR SANITATION PERMIT Permit N8. ...........z � (Complete in Duplicate) Date Issued ------ _ _4 Il Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the wdrk herein described. This application is made in compliance with County rd' ante o. 549. If JOB ADDRESSN LQ ,TI -• _.1 -- ° 1 Owners Name -' ---0-• ------------•----•-------------- - - Phone i1 -----------------------_--- Address-------- II t ---------------------------- ------------------------- Contractor's Name ----••---------------------------------------•----- ---------------•----•----------------------- Phone-----•- ---•---------------------- . �E Installation will.serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Mof9I ❑r Other E],1 r Number.of living units: __[____ Number of bedrooms __ _ Number of baths __1____ Lot size __ _ ___ _,I :.-________________________ Wafer'Supply: Public system Community system ❑ Private ❑ Depth to Water Table ________ ft. Character of soil+o a depth of 3 feet: Sand F Gravel ❑ Sandy Loam ♦ Clay Loam E] Clay ❑ Adobe�[' Hardpan E] I Previous Application Made: Yes E] No New Construction: Yes VNo ❑ !l TYPE OF INSTALLATION AND SPECIFICATIONS: �! (No septic tank or cesspool permiff R ubli sewer is available within 200 feet) Septic Tank: Distance from nearest well_ *i,._4 ��ista c fro_, found tior�.r�._j!":_.Mater' I �� ` [[�] No. of compartments------- ---....__Siz� .Liquididepth__._____ �--------Capacity___. Q- 1 - , t Dispos `Fieid: Distance from nearest w 14.._._____._.Distance from foundation ____-_, — istance to nearest lob lin``e��!.� _�-_tisr ' Number of lines___________ _____ �. ____..__ _Length of each line__________. C� _ri__..Width of french,_____�w_ _�`__?__________- Type of filter materi Depth of filter material._._____ Total length________ _S5___________________ _ ^* Seepa Pit* Distance to nearest w�efl_______________________Dist nce from found i fanc' 'to nearest lot 4i a✓ 0. r ►[ � Number of pits________________°_____Lining material--- Cesspool: _ Size: Diameter--.-.--- __Depth___.!!..._, Cesspool: Distance from nearest well------------------ Distance from foundation--------------------Lining material--------- u_.-------------------- ____.__.___ 1 --..De th---------------------------=------------------ -----Li uid Capacity i ------- Size: biometer------------------ - - � l ---------gals. Privy: Disfance from nearest well---------- ____________________Distance from nearest building__________.__II ❑ "Distance to nearest-lot line"''___"-_ i --- II „4 Remodeling and/or repairing (describe):------'------------------------------------------------------ -----------------------------•-- -----------------------•-- i=--------------------------- ----------------------------------•---•---------------------------•----------------------------------------------------------------•-•------------------------ --------------------------------- •---------------------- ----------------------------------------------------- ;i ----------------------------------------------------•-------•------------------------ •----------------------- li I hereby certify that I have prepared this application and that the work will be done in accordance with San'NJoaquin County ordinances, State laws, aTu d les and regulations of the San Joaquin Local Health District. I! (Signed)--------� --- i�----- -- -- " ~----------------------------------------------- - ------------(Owner and/or Contractoil. 6 (Title)-- 1! Plot plan, showingsize of lot, location of system in relation to wells, buildings, etc., can be laced on reverse side FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY-- ---------------------------------------------------------------------------•--------------- DATE-�... � ----- ----- REVIEWED BY r DATE-r- ----------------------------- - �--------------_---------- BUILDING PERMIT ISSUED-----------�-�-- ----------- DATE__.. I A roti s d recommendation ._ -- :�---------- ---------------------------------------- II ----- _ y --------- -- ------ --- -- 1 � It-s ' - ... ' -------------- tr1 �f- -� 3^r -----_ - ------------- -------------------------------------- ------------- I.. ; �a - ---- -------Q -.� �� s- ----------------------------------- -' - ------------- Date INSPECTION BY:. �= I �------------------ -- 'SAN J AQUIN 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 10-52 Revised W-2100f'