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C ) APPLICATION FOR SANITATION PERMIT Permit No, --- -�____ 'KA- �� (Complete in Duplicate) ' Date lssued�_z -op 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. JOB ADDRESS AND LOCATION_---_ __--,----__ _-_ - ---------- ---------- ------------------------------------------------------------------------------------ Owner's Name-------------------- - - - ------ - --- ----- Address ---- ----------- -- -------------------- Phone------------------------------------ --------- - -- ------0---------------------- Contractor's Name---------- --- -�-- _--��--- -----_-�" / j` -------------- Phone----� -Vii`--— Installation will serve: Residence k"Alpartment House ❑ Commercial J] Trailer Codrt ❑ Motel ❑ Other ❑ Number of living units: �_-_ mber of bedroom s,3 Number of baths -.`_-_ Lot size --------k-a_ I---_ -:-__- --_ Water Supply: Public system Community system ❑ Private ❑ Depth to Water Table, ft. Character of soil to a depth of 3 feet: Sand ❑ ravel ❑ Sandy Loam E] Clay Loam ❑ Clay EI Adobe Hardpan ElPrevious Application Made: Yes ❑ NoNew Construction: Yes No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.).— Septic41ankDistance from nearest we'll-----------------Distance from foundation--------------------Material_-----_----_-__-- Li Liquid depth --Capacity---- ---------- ❑ No. of compartments--------------------------Size-------------------------------- 4 p _ DispoDistance from nearest well-__-_----___- Diitance'from foundation--------------------Distance to nearest lot lineNumber of lines-----------------------------------Length of each line----------------------------- Width of trenchLLType of fi#ter material-- ______-�---- ------ - Depth of filter material-------------- ---,Total length-----------_------------------------SeepaDistance to neare w IIA19" /�� Distance f m�fou ation __ -__ -__-Distpce to nearest to line/, .J Number of pits- s__--_-Lining material'_ -'Size: D ameter__:'_- --------------Depth----sl ------- Cesspool: __ a ` 4 ess oo: Distance from nearest well_ __ _ _ Dep}Ince from,foundation__----____--._-___.Lining material__---__---_-_---___________-- p ❑ Size: Diameter-------------------------------------- -- ------Liquid Capacity--- -- gals. -- Privy: Distance froe est• well_ -------------------------------------------""""" - '" -� 4 -----_---_-_Distance from nearest ❑ Distance to nearest lot line_______________ _____ _____ all ---------------------------- ------------___ -------------------------------------- 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 s, and rule and -regulations of the San Joa in Local Health Dis rict. (Signed) - A-- •------�-- -------------------- r --------------- --- ---- -- - -� [ t ) roc w and/or ont or BY:----------------- ---�- --- --*---� '- - --------- ----------- ----- _(Title}----- °�- - - [Plat plan, showing size of to , location of system in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY-(:,-?----------------- ----------------------------------------------------- DATE le-------------------------------------------------------- REVIEWED BY � DATE-- - BUILDINGPERMIT ISSUED------------------------------------------------------------ -•-------------------------------------- DATE-------- - Alterations and/or recommendations:_.____ _- -- ---- ----------------------- --------------------- -------------------- -- ------------------------------------- ------------------------------------------------------ -------------- -------------------------------------------- ---------------------------------- - ------- ------------------- ----------------- FINAL INSPECTION __ __ ._° .-�_± '� - ^�/� �S 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 8-51 Revised W-2100