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® APPLICATION FOR SANITATION PERMIT Permit No. • ti ail' r/ . D d 9 �,(Complete in Duplicated Date Issued __�" _=_-�_�_•_ Application is hereby made tottetJoaquin" Local Health District for a permit to construct and install the work herein described. This application is made in compliance;with County Ordinance No. rA9. JOB ADDRESS AND LOCATION-----_4S_e_—&....... l --n---------------------------------------------------------------- ------- Owner's Name--------------------------------------MY-an-ti-el-------- �--�- Address--------------------------------•----•-•---.. ---- --------------------------------------------------------- Contractor's Name------------------------------ _r-_ '- ---- --- --- Phone-----?=-----_ 4 Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ ---_-�-P-f- ---1- Number of living units: __�___ Number of bedrooms __� Number of baths _/---- Lot size ------------------------ Water Supply: Public system Community system ❑ Private ❑ Depth to Water Table 0 ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe Hardpan ❑ Previous Application Made: Yes ❑ No X New Construction: Yes ❑ No ❑ PJ4 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_ DIC -e Distance fi-om�fou dation__ ________.Material � _ __________. _____Size_ - (,,��, No. of compartments____ __ ____________ ��s�-_?4-c�� .�-�-Liquid depth__�a.'_________CapacitY---�OO_--_-__• � Disposal Field: Distance from nearest well_40t�_.Distance from foundafion_,'1,7-----___.Distance to nearest lot line_/__C_`"___. Number of lines__/_____-__-- Length of each 7n----------- of trench___ __4E_' ______________ t-- ,------- f s Type of filter material__1___``_'71-__e-i--_K_-Depth of filter material___ .________Total length__,2.C?_ ____________ _ _____ _ � Seepage Pit: Distance to nearest well--�on-e______Distanc fromAftundsfi n�iameter-- Distance to nearest lot line__. _-r••-- .�xNumber of pits--------I------------Lining material- --- -�_�_ -----Depth--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----- ------------------------------------------•--------------------------------------------------------•---------=------------------------- { f Remodeling and/or repairing (describe):_________________ ___ ______ 1 r ------------------------------------•- r ------------------- -•------------------------------------------•----------------------•-------------------•------- --.. t I hereby certify that I ve prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State laws, and r es and regulati he San Joaquin Local Health District. (Signed)----- r r �'°-r-- { Contractor) r BY� '�'� -------------------------------------------------------------- (Title w' ' ^ (Plot plan, sh ing size of lot, locaf�on of system in relation to wells, buildings, etc., can be placed on reverse side]. FOR DEPARTMENT USE ONLY , APPLICATION ACCEPTED BY------------------ - ------------- DATE ------- t 3 ; - -- REVIEWEDBY----------------------------------------------- --------------------------------------------------------------------------- DATE------------------------------------------------------------ BUILDINGPERMIT ISSUED--------------------------------------------------------------•--------------------------------------- DATE------------------------------------------------------------ 1 Alterationsand/or recommendations:-------------------------------------- ------------------------------------------------------------------------------------------- ----------------•----------- ---------------•-------------------------------------------•--------------------.-------------------- ----------------------------------------------------------------------------------------------------------------------- ------------------------------------------ ---------------- --------------------------------------------- --------------------------------------------------------------------------------------------------------------. 1 f FINAL INSPECTION BY-------------- ------ -- - ------- -------------------------- Date.------. -------- SAN JOA UIN 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 8-51 Revised W-2100