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APS KATION FOR SANITATION PERMIT Permit Na3__�_?__-/-_- �"% �,.� �--� � [Complete in Duplicate) 38•��+ z/ t { 4 Z Date Issued __�� N____ S---- A. plication is hereby made to the an Joaquin Local Health District for a permit to constr dpi tall the work herein descr'sbed. This application is made in compliance with County Ordinance o. 549. j '] JOB ADDRESS ND LOCATION---moi-0 - o V ---- - --- ---- ---------------- ----------------------------------- ---------- ----,--y------- Owner's Name--------------------- ------- ------ ------ ------------------- -- Phone��_~ -� -- /----- Address ?�'► - Q ------------- ------------------------------------------------------------------------- --------------------------------------------- Contractor's Name-- ------------------------------ ------------------------------------------------------- ------ ---- Phone----------------------------------- Installation will serve: Resident ❑ Apartment House [] Commercial ❑ Tr ai r Court Motel 0 Other Number of living units:�l,!_ Number of bedrooms--------- Number of baths -?- Lot size _________ ______._______________ Water Supply: Pudic system ❑ Community system -❑ Private IM/Depth to Water Table -------- ft. Character of soil to a depth of 3 fe et- Sand ❑ Gravel E] Sandy Loam Clay Loam E] Clay E] Adobe Hardpan E]Previous Application Made: Yes E] New Construction: Yes Vo ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer'is available within 200 feet.) f Septic Tank: Distance from nearest well_________________Distance from foundation-------------------Material___-___________-__-__._______.________-----_---. ❑ No. of compartments------------- -----------Size--------------------------------Liquid4depf ------------------------Capacity---------- Dispos ield: Distance from nearest w II__ ___�_Ql_?istance from foundation_ _ Distance to nearest lot_-l'ne _ _of lines_______________ ____________ _Length of each line-________�_Q- __--f-_-_.Width of trench_____`.___�u__ ____.___--------- Number T e of filter materi 1 • � --- Type _- -' -- -- - -epth of filter material--------�--2-__-----Total length--------------Q�___ _ ________ -- �1 Seepage �it� 'Distance to nearest well----------------------Distance from foundation-----------------._Distance to nearest lot line_________________ ❑ ' Number of pits----------------------Lining material-----------------------Size: Diameter-----------------------Depth --------------___ d Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material___.______________.__________-_ Size: Diameter--------------------------------------De th--------------------------------- -----------------Liquid Capacity gals. , Privy: Distance from nearest well_________________ __ ___ __________ ________Distance from nearest building___. __--___-_-- ❑ Distance to nearest lot line---------------------------------------------------------=---------------------------------------------- Rdelin and/or repairing describe :-_ , ------------------------------------------------------------------------------- 111 --------------------------------------------------------- ------------------------------------ --------------------------------------------------------------------•-------------------------------------------------------------------------------------- ---------------------------------------------------------------- -----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------•---------------------------------- 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 regulations of the San Joaquin Local Health District. - (Signed) rr � ? = = [Owner and/or Contractor] By:------------------------------------------------------------------------------------------------------------------------------------(Title)----------------------------------------------------------------_ (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY ------------------------------------- DATE REVIEWEDBY--------------------------------- -------------------------------------------------------------------------------- DATE ------------------------------------------------- BUILDING PERMIT ISSUED--------------------------------------------------------------- ------------- DATE_----- --------- ------ Alterationsand/or recommendations------------------------------------------------ -------------------------------------------------------•------------------------------------------------------- ------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------- ---------------------------------------------------------------- ------- -------------- -------------------------------------------------------------------------------------------- ► FINAL INSPECTION BY;----------- _ __ -------------------- Date----------- - --- -- --------------------------- --------------- i SAN JOAQUIN LOCAL HEALTH DISTRICT 7 130 South American Street 300 West Oak Street 132 Sycamore Street 814 North "C" Street " Stockton, California Lodi, California Manteca, California Tracy, California ES-9-21vl, 6-51 Revised W-2100