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APPLICATION FOR SANITATION PERMIT Permit No. -_-G-39�-._.__ (Complete in Duplicate) Date Issued 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. 49. Sit 7 3 �,d�tf��y✓r3 - )67 h,�• JO$ ADDRESS AND LOCATIONolr 7 - °'' --- - - Owner's Name.----. ---- ------ - --- ---- --- ----------------------------------------- - -------------- -------------------------------------------- Phone------------------------------------ Address------------_---- ---•-- --- ---6 !�4_.� mss ------- ---- - ----- ---- .-- ---------------- --- -- --- ----------- --- / Contractor's Na e-------- 7ce �-�_�1--- - ------- ----------------- Phone [,, Installation will serve: ResidApartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other "j Number of living units: _.�_._ Number of bedrooms _ _ Number of baths I---- Lot size / W , ---- -- • 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 Olay Loam ❑ Clay ❑ Adobe❑ Hardpan ❑ Previous Application Made: Yes E] No %ew Construction: Yes No ❑ ,O f TYPE OF INSTALLATION AND SPECIFICATIONS: p (No septic tank or cesspool permitted if pu lic se 1s available within 200 fee/t..) "�/Q Septic T Distance from nearest well ___ __ ___Distance from foundation----- __ _t_! --------- --- No, of compartments-------_ - Size- - Liquid de th__.__ Ca acit R j Rte- ---- ----- �-��---�-�-- - q �1F? ------------------ P Y--��------------ Disposal Id: Distance from nearest weli__flo------Distance from foundation__�0K_-____.Distance to nearest lot lin _- ______ Number of lines_____ _______ __________ Length of each line_�!�¢ _ ------Width french.-A...----- length___ _ °__. "_ ___________ Seepage Pit: Distance to nearest well----------------------Distance from foundation___________________Distance to nearest lot line__-z.____--____- ❑ Number of pits----------------------Lining material-----------------------Size: Diameter-----------------------Depth--------------- ------------------ Cesspool: -----:----------_--------------- 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_______________________---------------------------------------------- - . 1� • 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 of the San Joaquin Local Health District. Owner and or Contractor (Signed)---------- , �" ---- � e� -- ----------------------------- ( ,_ / � 8r ` ------------------------ Title)-- ------------ --- (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be,placed on reverse,side). 00 FO 'DEK RT+AENT USE.-ONLY � APPLICATION ACCEPTED BY F = DATE------- --- -' ----------- + REVIEWED BY ---------------------------------------- DATE----------------------------------------------------------- ------- --- BUfLDINGPERMIT ISSUED-----------------------------------------------------------------------------------------------------• DATE------------------------------ Alterationsand/or recommendations:--------------------------------------------------•--------------------------------------------------------.... ------------------------------------ -------------------------------------------------- ---------- ----- ----------------------------- ------------ f J FINAL INSPECTION BY:--------- ---' ----- Date------- --- r 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 I ES-9-2M 10-52 Revised W-2100 i