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tV, f 14� " . s' ' " APPIICATION FOR "SANI ATM `PERIvIIT'" "" '"" ""�Perrriit No. [Comple+e in Duplicate}" V�Applicafion Date Issued __'___________ __ 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. 5,49, JOB ADDRESS AND LO TION------- -- G_(ilJ ------------------------------------------------------------- Owner's Name------------- -- ------ _Els C � --------------- Phone-----------`� -------------- Address------------------........ � �� --------- � 1 r = Contractor's Name-------------ti--------------•----- --•---------------------------------------------- Ur -- -------------------------- Phone--- --• --�- I Installation will serve: Residers��Apartment House ❑Commercial [] Trailer Court E] Motel ❑ Other f❑Number of living units. ______ Number of bedrooms ___ Number of baths __ Lot size -_----5��X14/ ______________________ Water Supply: Public system Community system ❑ Private ❑ Depth to Water Table ________ ft. Character of soil to a depth of 3 feet: Sand Gravel p ❑ ❑, Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe Hardpan ❑ Previous Application Made: Yes ❑ No ['F( New Construction: Yes [VNo ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if �bl'cewer is available within 200 feet. Sep#ic ank: Distance from nearest well-- Y______Distance from foundation____r_____________Material---------- 1_ :____ No. of compartments _ 1� __ X- -.Liquid depth._____�_______________Capacity-----��0;_c, p �---------Size----- --- Dispos Field: Distance from nearessteli_____�0_..Distance from foundation_____/.�___,___Distance to nearest lot line___ Number of lines-------_______ Length of each Ione-3_0J_-36.,_5_T.-Width of french___________-- ___________________ Type of filter material---/------ of filter material_____�3-----------Total length------1,�_-C)----------_-----------, Seepage Pit: Distance to nearest well______________________Distance from foundation------------------.Distance fo nearest lot )ine----------- ._`__. ❑ Number of pits----------------------Lining material------------------ ----Size: Diameter------------------------Depth------------------------ ------ Cesspool: Distance from nearest well-----------------Distance from foundation________________._Lining material-------------------------------------- F] Size: Diameter--------------------------------------Depth----------------------------------------- -`--:_,__Liquid Capacity----------------------------gals. Privy: Distance from nearest well--------------------------------------------------Distance froth'nearest building--________-_______________---___.______. ❑ Distance to nearest lot line__. - Remodeling and/or repairing (describe):-------------------------------------------------------------------------------------------- --------------------------------------------•---------------------------------------------------------------------------------------------------------------------------•------------------------ -------------------------------------------------------•-------------------------------------------------------------_---------------------.--------•--------------------------------------- ------------------------------- ---------------I-----------------------------------------------•-----------------------------------------------------------------------•--------------------------------------------------------------------------------------- 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, ------ tee.-w-.- u-------------------- _____________________________________________(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--------------p---- ----1 -- REVIEWED BY ----------- DATE T -- -------------------------------------- BUILDING PERMIT ISSUED---------•------------------------------------------------------------------------------------------ DATE Alterations and/or recommendations------------------------------------------------------------------------------•-------- -------------------- -------------------------------------------------------- ---------------------------------------------------------------------------------------•--------------------------------------•-----------------••---------- -----------------------•-------------------------------------------------------------------------------------------------------------------------- ------------------------------------------•-------•----------•----=-••- -•---------------------------------------- 74- FINAL INSPECTION BY: Date ------------ •- ------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American S+roe+ 300 West Oak S !�, 132 Sycamore Street 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California ES-9-2M 8-51 Revised W-2100