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l APPLICATION FOR SANITAT ON PERMIT it No. O_0_�4�__. (Complete in Duplicate EXPIRES ONE YEAR Da Issued --T� FROM DATE ____ Application is hereby made to the San Joaquin Local Health District for a pre'Mit to construct and installt e work herein described. This application is made in compliance with County Ordinance No. 549, 4 e JOB ADDRESSA LOCATION ''- �� --------------------------- --------------- on i-�� -- --- Owner's Name - ------ --- -• - - ---------A---------------- ------- PhoFt__Cl - � - Address.---------------- ---- �. ✓r_ - - ---------------------•-------------------------------------------------- Contractor's Name----la.�j ----------•------------- ----------------------------- Phone----------------------------------- Installation will serve: Residence a Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units:____ Number of bedrooms _A.__ Number of•baths X---- Lot size ___ _- _ -- Water Supply: Public system ❑ ,Community system [I Private k] Depth to Water Tabie ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam 1d Clay Loam ❑ Clay ❑ Adobe ❑ Hardpan E❑ Previous Applicatlon Made: Yes ❑ No A] New Construction: Yes k No ElFHANA: Yes ❑ No El 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_l,S.a-----Dista e from foun ion_�A___________.Materiaf______ _ ________________________ No. of compartments---An-----------------Size_ __-_�_�'�,� Liquid depth____±y,-14---1--------Capacity._��__�d�0--- 1line--4+� Disposal Field: Qistance from nearest welll��-- Distance from foundation_� _ ___.__.Distance to nearest to _________.-- dumber of lines------ ... y_-_..__ __Length of each linej_,(9®'____-.'.7q`Width of french_--'Al------------------------ Type ______ ________________Type of filter material/ _-Depth of filter material---A&P¢---------Total length-/,0_L7------- ______________________ to Seepage Pit: DistNumber of nits rest well_- Linin----maQteraal_e from foundSize:foundation -----------------------.DistanceDepthst.lot line---------------- ❑ pits ------------- 9 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___._._.________--_--------_---_.__.____- I ❑ Distance to nearest lot line------------------------------------ ---------------------------------------------------------------- ---------------------------------------- Remodelingand/or repairing (deseribe):-------------------------------------------------- -•--------------------------------------------------------------------------------------------------- ------------------------------------------- -------- ----------•---------------------------------------------------------------------------------- -------------------------------------------- --------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------- -------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- -------- - - I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, Stat laws, and rules and regulations of the San Joaquin Local Health District. (Signed)-- ----- - --------- -------- --------------------------------------------------------------------------(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 r APPLICATION ACCEPTED BY---- - � -------------------------------------------------------------- �.------------------ REVIEWEDBY---------------------------------=----------- -------------------- ---------------- ------------------------------------------ DATE---------------------------------------- ------------------- BUILDINGPERMIT ISSUED------------------------------------------------------------------------------------------------------ DATE------------------------------------------------ ------------ Alterations and/or recommendations------------------------------------------ ------------------------------------------------------------•-----••-------- ] -------•------------------•- -----------------------•----- -----------------------------------------------------------------------------•-- \ t" --- -- ------------ ----------- Y _________ ________________._____._.__ _____________--i_____---______ ------ _ ____.____-.______________________----.--------._-..________..___-____..__________..___________----__-____..____-____-_-__1-1 _____._____ FINAL INSPECTION BY:..--04 I I --------------- ------------- Date---- ------------------------------------------- SAN ------------ ---------------- SAN JOAQUIN LOCAL HEALTH 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 Revisep 1.57 FRCOJ ti �- s