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,Y P LCA ION FOR SANITATION PERMIT Permit 02 — (Complete in Duplicate) Date Issued��/- - S_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. 549. JOB ADDRESS AND OCATION-_":1---- 31--------/ f ------------ Owner's Name-- - lti'' ( Phone ,3 Address------..-------- ----,>------ Contractor's Name---------------- --- ---------•----- =•-------------------------------------------------------------------------------------------- Phone----------------------------------- Installation will serve: Residence [A► Apartment House ❑ Commercial ❑ Trailer Court p Motel ❑ Other ❑ Number of living units: ---t--- Number of bedrooms _- Number of baths __ ___ Lot size --------- ---- Water Supply: Public system X, Community system ❑ Private ❑ Depth to Water Table -------- ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe ( Hardpan ❑ Previous Application Made: Yes Rj No ❑ New Construction: Yes CK No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: �RV� (No septic tank or cesspool permitted if public sewer is available within 200 feet.). 1' from foundation------/0____-Material----". Septic T�n'k: Distance frorri"nearest well__-__-�-~"'�" Distanc No. of comparfinents----------1,.*-'-----Size----� Liquid depth-----------Arl ----------Capacity---- ----------- ---- 4 Disposal Wield: Distance from nearest well______--"""'"Distance from .founda�tijon---I�d.__-_"""-Distance to nearest lot Number of lines--.------"" __ g +� $ .Width of french---- Type _Len Length of each line"�S�- "/__Q " rr to I p g - p li Total length ---4----------------------- Seepage ---------------------- See a e Pit: Distance tloenearestmaterial Distance ffrJotmrfoundation-------------------Distance to nearest lot line--__------------_ ❑ Number of pits----------------------Lining material-----------------------Size. Diameter-----------------------.Depth--------------------------------- Cesspool: Distance from nearest well-----------------Distance from foundation-----_-- _-- ------Lining material--------------------------.__-----_-_. ❑ Size: Diameter----------- --------------------------Depth------------------------- -------------------------Liquid Capacity------------•--------•--_-gals. Privy: Distance from nearest well--------------------- ---------------------_-_Distance from nearest building ❑ Distance to nearest lot line--------------------------------------------------- Remodeling and/or repairing (describe):-----------------A --------------------- -------------------------------""--•---- -----------------------------------------------I——------------------•-----------------------•---------------------------•--------------------------•---•------------------------------------------------------------------- I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin Count ordinances, State laws, and rules and regulations of Ire San Joaquin Local Health District. (Signed)_- -R -- ----------------•-•- -. --------------------------------------------- --------------------------(Owner and/or Contractor) BY- - ----------•-•-----------------------------------------------•-- ----------------(Title)---------------------------------------------- ----------------- (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). I t FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY-----------i-/--—/ ------------------------- DATE-- 2 ------ ,•. REVIEWED BY------------- ------------ ------ ----- ------------ ----------------- DATE ------ BUILDING PERMIT.ISSUED----------------- DATE- !� Alterations and/or recommendations:-_---- _ �' / (, y -� ------ ___x-------- ------------ -•----------------- -- -----------------•-----•------------•-------------- -----------------------------------------------------------• --------------------- ------------------ ---------------------------------- --- ----------------------------------------- ------------------------------------------------ -------------------------------------- ------ --�------------------------------------------- 1� FINAL INSPECTION BY:------ --- ---------------------------- ------- Date- ---------� --------------- ------------ SAN JOAQUIN 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 8-5! Revised W-2100