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Permit No. - APPLICATION FOR SANITATION PERMIT Duplicate) Date Issued ._0__-__ ' (Complete in Dup �k_L—/ Applica{ion is hereby made to the San Joaquin LocaOrd�nanceDiNoc549r a permit`oconstruct� "install the work herein described. This application is made in compliance withY 7 Ile"" `-�---------•--------------- .l%�` , ` '0 ---- - JOB ADDRESS AND LOC ON.._--------- ? ---------- Phone--•-------------------------------- Owner's Name___________________ _-* r�------ �c - ---------------------- ---- ---- - r `''^- �� a ---------- ---------- -------------------------------------------------- -------------------------------------- ------------•----•----------•-------- Address--------------- -------Address--------------•------- ------ - ------------------------------------------------------------------ -------- Pone.------•--•-------•---------------- Contractor's Name------------- --------------Hous Other Installation will serve: Residence e�Apartment Nouse ❑ Co martial ❑ Trailer Court ❑ Motel ❑ ❑ Number of living units: - ----- Number of be #_(I mber of baths _.-_ tot size ___ -----t Water Su Public system ❑ Community system El Private Depth to Water Table ____-___ ft. Supply: Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe g?- ardpan ❑ Character of soil to a depth of 3 feet: Sand - Previous Application Made: Yes ❑ No Lys New Construction: Yes &No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) r aerial Septic T k: Distance from nearest well,�_P_"10'Distanc from f undation.-- - Ca acit A�-s --- No. of compartments Size_.___I -4- ��---Liquid depth /�3�------ p Y --------- Field: Distance from nearest wel0l _Distance from foundation.-,/.0.....-_..._-Distance to nearest lot line -�---.� Disposal - ______ Length of each line__ _-_-Width of trench----A- ------ ------� . Number of line ---------- g _f - - De Depth of filter material_ 9 Q __---Total length � 11.---- Type of filter material�i �"�''-�----• P ��" Seepage Pit: Distance to nearest well______________________Disfiance from foundation__--__..___-__..__-.Distance to nearest lot line----------------- - - Size: Diameter----------------------- Depth--------------------------------- ❑ Number of pits- - ------------------Lining material.---�----------------- ----------------- ining Capacity l ___Distance from foundation Cesspool: Distance from naresfi welt___ - Liquid --------------------------- gals. ❑ Size: Diameter------------------------------------- Depth Distance from nearest well______------------------------------------------ Distance from nearest building__________________________________________ Privy: --------- --------------------- 0 ----- -------- ❑ Distance to nearest lot line------------------------- ---------- --------- ---------- --•---•----- ------------------------------------- ------- Remodeling and/or repairing (describe):------------------------------------------ --------------------------------------------------------------------------------- ------ ------------------------------------------- ---------------------------------------------------------------- -------------- --------- ----- --------------------------•------------•---------------I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State laws, and rules and regulations o the a0 Joaquin Local Health District. ' -:k -----------------------------------(Owner and/or Contractor} (Signed) 'C - -- �= 13y:._.., J .cl., .�t ,a «... r ` ..�.. .�a----------------- (Tit e - -- -- ---------------------- (Plot plan ' owing size of lot, location of system in relation to wells, buildings, etc., can be placed an reverse side]. FOR DEPARTMENT USE ONLY ---- ---- ---- DATE-- -- ----------- -----------�----------------------- APPLICATION ACCEPTED BY--------------------- DATE._ _"-�,,-'��---�---- -------------------- REVIEWEDBY-------------------------------------------- - BUILDING - --- - - - - -- ------------------------------------------------- -------- DATE---------------------------------------------------------- BUI LDI NG PERMIT ISSUED---------------------- Q , . --.- ATI estigns and/or a ommendations: ;:; - ;; - ----------- ------- - -----•-------•---•-------------• )-- F --------- ---- ~ •- ,�f _ ~�------f ------ - -"4 ' � ---- - '`- �. ��• + ------------------ --- --- -------- ---- -- - -- - l —J" ------------------------ Date . FINAL INSPECTION BY--------------- - ------------- ------ -------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 300 West Oak Street 132 Sycamore Street 814 North "C" Street 130 South American Street Trac California Stockton, California Lodi, California Manteca, California y ES-9-2M ;' - Revised W-2100 _ '