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„i APPLICATION FQR,SANITATION -PERMIT ' Permit [Complete in Duplicate] f Date Issued __. i 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. 5 ._ i ADDRESS AND LOCATION --- -9------- ; ------ ---------------------------------------- ---------- JOB- -- - - �{— Owner's Name------ + 1.�„�; - } -- - =------------1-------------- Phone --- --- t` � -------- .,T ---------------------------•----------------------------------= -----------------------------------------------------. ---- ---- Phone----------------------------------- Contractor s Name__ Installation will serve.. Residence Apartment House Commercial. E]Tra-4er Court ❑�- Motel E] Other [3Number of living units:'__ZImmunity ber of bedroomsNumber:of baths :____ Lot size S?-Q_-__d�____________________rWater Supply: Public system system []—Private E] Depth to Water Table :_..'___ ft. Character of soil to a depth of 3 feet: S��Ne ravel Sandy Lo�7�No Clay Loam ❑ Clay ❑ Adobe ardpan ❑ C.1 Previous Application Made: Yes ❑ No.Construction: Yes ❑ FHA/VA: Yes ❑ No E TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or`cesspool oermitted if public sewer is:available within.206 feet.) Septic Tank: Distance from nearest well_______________ _ Distance from foundation_' ------------------ Material ______-_._____.________.___________...._.______- No. of compartments---------------- -------- ;,Size ------_-------- ------- Liquid depth------------------------- Capacity ----------------------- Disposal Field: .Distance from nearest+well_-_..______g,___Distance from foundation _________________.Distance to nearest lot line________________ ❑ Number of lines------------------ ---------'- Length of each.line__------------------------•--.Width of french ----,------------------------------ Type of filter mate'rial_.------- '-___.-_.__.--IDepth of filter material ______________________Total length --___-_-__________.___________-_____-___. Seepage Pit: -Distance to nearest'well_-______"-_'________Distance from foundation_____ ---__---_____.Distance to nearest lot line ___________.-_-_ a ❑ p' Lining "material --_------ .-__---Size: Diameter ------------------------ Depth ------ Cesspoa Distance from neare�t well Distance fron),foundation --- /�_.- Lining material.- .1_ r_-_ ____________�___ Number o its_:_.__c_ _____ Size:er Liquid Cap6city3_0Q- 9 f-. - - - r..r. r Privy: Distance fr'omtriearest vrelL______________ ______________________"_ -Distance from nearest building ------------------------------ ___.._____-- ❑ Distance to nearest lot line:- --- =` - .. - ------'-------------------------------- ----y--- �_. L_ , 4 Remodeling and/or repairing escribe):-,-- -- ---- ------ -- - ------------------------------ ------••-.----- Y'k = ( � ------- -- ------------------------------------- --------------------•-- -. -... ------- ----- ------------------------ -------------- I hereby -certify that.l have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State laws, and rules and reguli ionsfof the San Joaquin Local Health District. { ------a ��' , -,-. {Owner and/oror ContractorSi Signed) -12, ,fil/ --- �.------- --- i4 I By:--- --------------=-=---------------------- -- _ ------------------ -------------------(Title)---------------------------------------------------------------- (Plot plan, showing size of lot, location, of_systern in relation to'wells, buildings, etc., can be placed on reverse side). j T '.� * ",' `FOR DEPARTMENT USE ONLY" APPLICATION ACCEPTED -BY--------------------- -------------------------- DATE-----------•--- ------------------ ------ DATE--------------- F ................. BUILDING PER ISSUED. DATE_ .-------------- --------------------------------------------------- D T Alterations and/or recommendations:------- ----------------------------=----------•----------------- ----------------•--------------------- • --- ------ --._.. ------- •------------------------------------------------ -------------------------------------------------------------------------------- ,,k.___ -----------------------------------•---------------------------------------------------=---- -- ----- ----- -------------------------- - // - FINALINSPECTION BY: ------ ----- ••---------- --�--- ---------- -- ,_ _ Date ------7--------=-------- ----------------------- -- -- -- rt - ------------ SAN JOAQUIN LOCAL EALTH DISTRICT 130 South American Streef 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 -?.CO.