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Ir o APPLICATION CATION FOIZ SANITATION PERMIT Permit No. ..��7•r7'• r (Complete in Duplicate) I Date Issued _Z_ o!V_^�3 Application s 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. 549• 13 /1 i` JO ADDRESS AND LOCrA ION.- .( Ori - „ � I Owner's Name__ - . -._ - �p � ,� --- ----------- --------------------------------------- ----- Phone.--dem Address------- - - I - -------- .. Contractor's Name--• - - - ----- /} /�•/ ►// ' --•-----•-- Phone----- -•--- � ' Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ �# Number of living units: ---?-__ Number of bedrooms - Number of baths .-/---- Lot size ----1 d U Water Supply: Public system ❑ Community system ❑ Private�Depth to Water Table --/?'ft. Character of soil to a depth of 3 feet: Sand Gravel ❑ Sandy Loam ❑ Clay Loam E] Clay [IAdobe❑ Hardpan ❑ ¢ G Previous Application Made: Yes ❑ No New Construction: Yes ❑ No [2t— 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---------------_Distance from foundation-------------------Material-_---__---- ^ No. of compartments------------- Sizo_ -------------------- ---------------Liquid depth------------- -------- Capacity------ ------�-r--- Disposal Field; Qumbee from nearest w ------------- --— Distance from foundation-----IA--f Distance to nearest lot line---- -__-----•, Number of lines------- -------- Lenpgth of each line------_A,_)7��__.-.Width of trench---tv ------------------------- Seepage 1-- --------- V, Type of filter material--f_� fl�__De th of filter material-----/9- -_-_Total length_--- :� __--------_ - Seepage Pit: Distance to nearest well---`-0-a_"'---Distance om fo clation___. X!-_.Distance to nearest lot line_-- ---f--- Number of pits------- -----------Lining material--- -Size: Diameter -- r'- Depth-----/- r (/7`� Cesspool: Distance from nearest well-----------------Distance from foundation-------------------- Lining material ❑ T _ Size: Diamefer. -------- ---------------Depth------------------- -_..--------------------- ------------Liquid Capacity------------------.---- �_ - - _ ---gals. Privy; Distance from nearest-vrell ___________ ---_---._Distance ---;_fror*� nearest buiidin ---------------- g----- ------------------- ---------------- ❑� Distance to nearest lot line...__----._---_ ------------------------------------------------- ---------- Remodeling and/or repairing (describe)-------------------- ----------- ------------------------- ------------------------•------------------••-------------------------------•--------------=---- -_ - , ----------------------------------------•----•---------•---------------------------------- --------- -- 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. r (Signed)--- - --- ---------- ------------- By:--- ' .� Title (��-astd{�or Contract - or) ( ' }./ice (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---_ DATEI ----------------------------------------------- REV IEWED BY -- - ----------------- ------------------------------------------------ --- -- - --- ---------------------------------- ------------------ --------------------------------------- DATE BUILDING PERMIT ISSUED----------------------------- �------ --------- ---------- --------•-------- ------------ ---------------------------------------------------------- DATE------ -- -- '� Alterations and/or recommendations-------------------------- ----------- ---------------------- - ---------------•---------------------------------------- ------------------------------------------------------- FINAL - -- --------------------- FINAL INSPECTION 'BY----------- --- r -------------- - ------------ Date-------- SAN - --SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Street 814 Noi•th "C" Street Stockton, California • Lodi, California Manteca, California Tracy, California ES-9-2M 10.52 Revised W-2100