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,h APPLICATION ICOR SANITATION PERMIT Permit No.J _______�_ (Complete in Duplicate) ( ~� Date Issued _/_-,1 _4 a 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 _o. 49. JOB ADDRESS AN 'L ATION___-_----�` _ �✓--- ------ -- �- Phone Owner's Name 1�/ Address---------- ------------ Contractor's ----------Contractor's Name--------------'__-•__-- _ --- - .-------- Ph one- Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other El Number of living units: �L Number of bedrooms , Number of baths --- __ Lot size _-_ a -. Q --- ------------------------ Water Supply: Public system Community system E] Private ❑ Depth to Water Tablea-rff. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adob Hardpan ❑ Previous Application Made: Yes ❑ No_Ur New Construction: Yes ❑ N_04�, a 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-_______________Distance from foundation--------------------Material ____._____-.___________..____--_ l r x l /� � ;1 No. of compartments-------------- -----------Size------------------------•------:Liquid depth--------------- ----------Capacity------ -------------- Disposal Field: 3 Distance from nearest well_---_------------Distance from foundation-----._-------------Distance to nearest lot line_____________-__. Nmber of lines-----------------------------------Length of each line------------------------------Width of trench. Type of filter material------------------- -----Depth of filter material---------------- -----Total length---"-------------------------------------- -. , See pa e Pit: Distance to neares# well ._ __Distance from, foundation_ e-2 Distance to nearest lot line_- Number of pits.- ----- ------ ming material - ----- Ize: Diameter____ c , 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._._____..__._ --r--- —" t ----------------------------------•------------------------------------------------------------------------------------------ r Remodeling and/or repairing (describe):_____.._ Qf _---- __p/ «-- ------•----------------------- E ------------•----------••-------------------------•------------------------------- ----------------------- -------------- ----•----------------------------------------------•--•--------•------ I -----------------------------------------------------------------------•--------------------------------------- I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin Coun ordinances, St aws; a d r les and regulations of the San Joaquin Local Health District. % S (Signed)-....... --- �.. # ` (Owner and/or ontractor) Title . . — . (Plot plan, showing ize of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side}. FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY--- REVIEWED 1 ------------------------- DATA _.-;----------- ------------------------------ - REVIEWED BY ------------- 51,---- _ DATE -------------------------------............. UfLDING PERMIT ISSUED---------------- ---------------- -------------------------------------- ----------- DATE. Alterations and/or recommendations----------------------------------- %dt--- , --------------------•------------------------------------------------------ •--------------------------------------- FINAL INSPECTION BY:1,- --- Date------ ------ SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Street $14 North "C" Street Stockton, California t Lodi, California Manteca, California Tracy, California ES-9-21v1 10-52 Revised W-2100 f]