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APPLICATION FOR SANITATION PI RMIT Permit No. (Complete in Duplicate) r Date Issued 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 wiO/Q&unty Ordinance No.'549. JOB ADDRESS AND C TION ------------ -------" '------------------------------------------------------------------------ -----------Owner's Name----------- -7 - ---- ------ -- ----- ------------ - -------------------------- Address-------------------------4/------------ -------..Address------------------------=4/------------ ----------- --- ------------------------------------- ------------------------ Contractor's Name---- --------------------------------------------------- ' ------------ ---------------------------------- Phone. .Installation will-serve:, Residence [Apartment House ❑ Commercial ❑ Trailer CourtMotel E] 'Other l__' ❑ " Number of living units: ___)___ Number of bedrooms . _ Number of baths __. L t size❑/(d_ _-- Water Supply: Public system RT Community system ❑ Private ❑ Depth to Water Table ________ ft. Character of soil to a depth of 3 fee+:L. Sand ❑ Gravel ❑ Sandy Loam ❑, Clay Loam Clay [dobe E] Hardpan E] Previous Application Made: Yes ❑ No 9�XNew Construction: Yes Egro�`No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.)__r Septic Tank: Distance from nearest well--- Distance from foundation,_I_y------Mzkteriai_ No..of compartments________:_ __._.__Size_ _ 1_ ------Liquid`depfh__?w, _...........Capacity_!_Q y lbDis osal Field: Distance from nearest weil__� __-_-_-°.Distance ,from foundation_ _ i t se to nearest lot line____ ___________ Number of lines____ ..•�. Length of.�each.line �__ # �-" iiPi of trench - g Type of filter material--_______Depth of fiber materia___ _ _-.-_____-_Total',length___ Seepage Pit: Distance to nearest well______________________Distance from foundation__-_ -'-----.Distance to nearest lot line----------------- 1-------- ❑ Number of pits----------------------Lining mer ial-----------------------Size:_Diameter-T- I---------- Depth--------------------------------- Cesspool: Distance from nearest well-----------------Distance from foundation._.-_.--------------Lining material___-_--"___________________________ ❑ Size: Diameter----------------------------- ----De th-----------------------------------------------------Liquid Capacity----------------------------gals. Privy: Distance from nearest vrell_________________ -------- -------------------Distance from nearest building.__- _-____.______________-.---_ y ❑ Distance to nearest lot line----------------- -----------------------------------------------------------------------------------•----------------------- -- # a F - i Remodeling and/or repairing (describe): `=-------------•"--•-------------------------•------------•--- --------------------------------------...---------- i ---------------------------------------------------------------------•----•------------------ ----------------------------------------------•---•-----------------------------------•-------------------•------------------ k _____________.._.____.-_____-_.____---.._______..___.._____-___-____________-----..--.-________ __-_---____--_----_-_-_____-_______-____________.-__...._-__-.________----__________-_-_.____._____._._'_____-_---__---.---_ --------------------------------------_--------------------------------------------------------------------------------------------------------------------------------------------..._________________________-______-._.__.- r r I hereby certify that I have prepared Phis application and that the work will be done in accordance with San Joaquin County ordinanceASSfT laws, and rules and reg ions of the San Joaquin Local Health District. (Signed)--- ----- --- --------- Vi ; -------------------------------------(Owner and/or Contractor) By-----------------•-----......____•-----------t = ------------(Title)---------------- ------=----------------------------------- --- r (P16t plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side]. FOR DEPARTMENT USE ONLY REVIEWED BY__ACCEPTED BY--"-------' "' ----------------------------------------------------- -. DATE---./ - ----- DATE--- � ----- ----- - --•-------- BUILDING PERMIT ISSUED-----_------- � TE - Alterations and/ reco manda+ions:-_� =; - + -•""_- _^� - __ L:------ f °` - = ---------------- ►.. ' V _� ------------ -----•----•----•---• ------------------- -•------------•----- ----------------------------------------------------------------------- ----------------------------------------------------- -------------- --------------------------------------------------------------- ------- --- ---------------------------------------------- ------------------------------------------------------- FINAL -------------------- --------------------------FINAL INSPECTION BY:- -------- Datelt.-_ ..� 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 10-52 Revised W-2100 - l