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APPLICATION FOR SANITATION PERMIPermit No. _..___ ., t (Complete in Duplicate) -�4 qj� ` Date Issued f 5 Application is hereby made to the San Joaquin Local Health District-for a pwmit to con truct and install the work herein described. This application is made in compliance with County Ordina No. � e JOB ADDRESS AND LOCATION J� �� ICI -� . Ig ............. s7dc ' d , Owner's Name ! ��''�� P e_. _ - w w Phone-69 �•• Address-----------------•-•--• •--••--•••-•......-----•--- _. 177 � •.. e ~�Contractor's Name-- ��_-------------------------- --- -------------- -- ----- ----- -- - Phone. --•• •- •--•• ---- Installation will serve: ' Residence %,Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: I-__ Number of bedrooms 3__- Number of baths ./ —ot size .....i&3__x___/._Z __-,.,;: Water Supply: Publicl system ❑ Comnn''ity system Private ❑ Depth to Water Table ........ ft, Character of soil to a 4epth of 3 feet: $and ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe;K Hardpan E] Previous Application Made: Yes ❑ No R New Construction: YesA, No ❑ FHA/VA: YesX No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or'cesspool permiffedF public sewer is available within 200 feet.) -- a Septic Tank: Distance from nearCst well Distanc'e/ fnRm foun tion l Ma}er'aI .. No. of compartm�,rits-----.!1'----------------Size__._Y-X_�X_ ----..•Liquid depth_. ..?'---- CaFus�i Disposal Field: Distance from nearost well. -._Distance from foundation...../a......Distance to nearest lot line Number of lines _'_,3_____________ Length of each line--------e -_ Width of trench r2 Type of filter matetial_ _ ___ epth of filter material---------/S-----__Total length............. '.• Seepage Pit: Distance to nearest well , ----------Distance from foundation-..._/v _. 4nce to nearestlot1-rip. I M S Number of pits__. _ ,t_:___ fining ma#erial_ -G �ze. Diameter . __ De ,± . ' r. Cesspool: Distance from nearest well_________________Distance from foundation-----------------__.Cinmg mer a_ __..,___. .�•....._, El Size: Diameter__-- ---------------------------- Depth - -- ---•- --- -•,Liquid Capacity gals 9 Privy: Distance from nearest well-- ----------------------------------------------Distance from nearest building---------------_--------..... ❑ Distance to nearest lot line 7 Remodeling and/or repairing (describe)_______ _________ " t - -------- - ----- --- ----------------------- ------- ----- ---------------------------------------------------------------- --------------------------------------•-------------------------------- . --- ..... --••• ......-•--...._ ---- ------ - ------- ----------------------------- -------------------------------------------------------------------------}t............... -••----------------------------------------- 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 reguly ions of;the San Joaquin Local Health Pisteict. (Signed)-•-••I ---- == ' Y` J ----------------- ----------------------------(Owner and/or Contractor) gY ---•• ------ ------- ------- -----=-- 9=---- . --(Title).......................................................... (Plot plan, showing sine of lot, location of system in relation to wells, buildings, etp., can be placed on reverse side). FOR DEPA$TMENT USEONLY` APPLICATION ACCOTED BY--------------------- --------- -- -- b............ -------`' ------- DATE--------- REVIEWED BY . ------------------- ----- :�--------, ------------------ DATE---- BUILDING,PERMIT ( SUED-__ ------------------------------------.. DATE------------- a Atte nsand/or reaorrnm ions. . - • =------------------------•-------------------------------------------------....................................................................... -------••--------------------- ------------ -•-- ----------------------------------------------------------- FINAL ---- ------------ ---------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 Revised 1.57 F.P.CO.