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2- APPL ATlON FOR SANITATION PERMIT ' r Permit No. ----- ----- w I - (Complete in Duplicate) Date Issued i u' n Local Health District for a permit to construct and install the work herein described. Application is hereby made to the San Joaquin This application is made in compliance with County Or finance No. 5 9. JOB ADDRESS LO TION----------------------- -�--r----- g' �0 - Phone e--- Owner's -Owner s Name ____________ "--------------------- 2.1 " '" ; � ---------------------------------------- - : _ .Address------- -- -- ` Contractor's Name----- --- ----------------------- --------------------------------------------------------- li ---7-�- - -- ---"---- ------•------------- Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motpl ❑ Other ❑ 5 x 1_x.0------------------------- Number of living units- umber umber of bedrooms _-R- Number of baths.---/--- Lot size ____ ____ _________ S Water Supply: Public system Community system ❑ Private ❑ Depth to Water Table -------- ft. Character of soil to a depth of 3 feet: Sand Gravel ❑ Sandy Loam Clay Loam El Clay El Adobe /Hardpan ❑ o Previous Application Made: Yes ❑ No [� New Construction: Yes No ❑ !v • �j TYPE OF INSTALLATION AND SPECIFICATIONS: ' (No septic tank or cesspool permitted if publ!s s wer is available within 200 feet.) / /� Mater'a -- -------- a Septi ank: Distance from nearest well:_-�" Distan fro foun tion___;_____[1___ n No. of compartments_____----- "__ -- 75 --- --Liquid dep h___--.____�__-_-____Capacit _ ! /-- Size_----- ---- - --- Y------- - �; Dispos Field: Distance from nearej)i -_-Z_____ ._.Distance from foundation___'____ _ _________Distance to nearest lot li T� ______-- Length of each line___ ___ Width of trench_--._____ Number of lines-------- ------ - 9 - --- -- t#---. --------------- Type of filter materi epth of filter material_______ ______ __Total length______________ ____ Seepa a Pit: Distance to nearest w I_ "__ Distance m foundation_ Qista cre/to nearest lot ine___�3________ Number of pits__________ ________Lining material__ Si e:`Diameter_____o _ --------Depth... ----------•- Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material-------------------------------- s ,, ❑ Size: Diameter-------------------------------------Depth----------------------------------------------------Liquid Capacity----------------------------g I ____Distance from nearest buildin Privy: Distance from nearest well------------------------------------- ------ g-------------------•--------•------------ � ❑ Distance to nearest lot line--------------------------------------------------------- ----------------------------------------------------------- Re o n d/ t re icing {d sc`ribe):-- ------------------------ -----------f ---------------- ----------------------------- ----------------------------------------- ------, ------------------------------------------------------------------------------------------•----------------------•-----------------------...--{ I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State 1 and rules andregulations of the San Joaquin Local Health District. (Signed : -� ^' ----=---- ----------------------------[Owner and/or Contractor) By.............................. - -- --..__ Tale ----------- -- - ------ --------------- - ----- --------- (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED B __ - _-.-- ------------------- - DATE REVIEWED BY DATE --------------------------------------------- BUILDING PERMIT ISSUED-------------------- ---------------------------- ------ — T �,�� '---- DATE ---- Alterations - " Alterations and/or recommendations:___ 1�-`S-1 --- ---------• -----------• `{' '"""""" ---"� ------` ------"------------------------------ -. --- - --------------- --------•----------------------------------------------------------------------------- f` FINAL INSPECTION BY-------------------"��`.��,�"-''"------------------------ Date----- -------- ---------------------------- • ------------ SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American S+root Soo West Oak Street 132 Sycamore Street 814 North "C" Street e Stock+on, California Lodi, California Manteca, California Tracy, California ES-9-2M 8-51 Revised W-2100