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ii�� APPLICATION FOR SANITAT��1-�P��.:= mit No_ ______________ [Complete in Duplica ) E:PI � j D YEAR ��-,p D to Issued ----{_N__--__l__ t�2 I3A. Application is hereby made to the San Joaquin Local Health District for a permit to cons ruc an ins a e work herein described. This application is made in compliance with County Ordinance No. 549. JOB ADDRESS AND LOCATION �� h'�,± � -1 � Owner's Name____d�--- �k,-_/ _0 -------------------------------- Phone Address---------> -• r rb� _------------ Contractor's Name_�t.�c__ �-- ------------------------------------------------------ Phone----•-------• •---------- --------------------------------------------------------------------------------------------------------- -------- ---------- Installation will serve: Residence [f Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: J___ Number of bedrooms __3__ Number of baths ./--- Lot sizeel�✓.Qa '_ ___________________-___.______ Water Supply: Public system ❑ Community system ❑ Private 5� Depth to Wafer Table 1-117- ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ `<Sandy Loam U Clay Loam ❑ Clay ❑ Adobe❑ Hardpan ❑ Previous Application Made: Yes ❑ No ® New Construction: Yes ® No ❑ PHA/VA: Yes"i-j No ❑ TYPE OF INSTALLATION AND SPECIFICAfION.S:., n . (No septic tank or'cesspool permitted if public sewer isavailablewithin 200 feet.) Septic Tank: Distance from nearest well- j 7 -------DistagQnce from foundation---/_O.'-----_Material--- ---------------------------- No. ---------------------------No. of compartments---- -----------------Size-If _ -- --------Liquid depth------y----------------Capacity.fA------------- Disposal Field: Distance from nearest well4rO------------Distance from foundation_I_Q_'___________Distance to nearest lot line____'_----------------- Number of lines________ ____ _________ _ __Length of each line__:___-_-_------------Width of trench_3e�________.___________.____ Type of filter materi� l '__Depth of filter material____�tp_____________Total length___ f)-------------------------- ._ Seepage Pit: Distance to nearest well__________-..___Distance from foundation___---_-____-_____.Distance to nearest lof line----------------- ❑ Number of pits----------------------Lining material-----------------------Size: Diameter-----------------------Depfh--------------------------------- Cesspool: Distance from nearest well-----------------Distance from foundation------------------- Lining material-------------------------------------- F1Size: Diameter--------------------------- -----------Depth----------------------------------------------------Liquid Capacity------------------------ -gals. Privy: Distance from nearest well_________________________________.__-_-_______-_Distance from nearest building------------------------------------------ ` Distance to nearest lot line [] ------ ---------------------------------------------------------------- ----------------------------------- Remodelingand/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 1 ordinances, S.tafe laws, .and rules and re+�ulatio f the San Joaquin Local Health District. i (Signed _ ----------- 0 .------------------------------------------------------- ---------------------------------�..---(Owner and/or Contractor) E rt rt -• _ — v B (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 7._-j7-47f- REVIEWEDBY--------------------------------------------------------------------------------------------------------------------------------- DATE------------------------------------- - 1DATE • - ----•------------- BUILDINGPERMIT ISSUED----------------------------------------------------------------------------------------------------- DATE------------------------------------------------------------ Alterationsand/or recommendations-------- ------------- --------------------------------•--------------------------------•••-------•----------•----------------------------••--- -•--------------------------------------------------•-----------------------------------------------------------------------------------•---------------------•-•----•-------------------------------------------------------- --------------------------------------------------------------------•--------------------- - --•---------------------•- ------------------- --------------------------------------------------------------------------------------------------------I------------------------------ - ------------------- i ------- FINAL INSPECTION BY D -Z -- ----•---- _-- - -- - - ---------------•--------- ----- ate -•--------------------------------- i 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 k ES--9-2M Revised 1.57 F.P.CO.