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`� APPLICATION FOR SAN TATION PERMIT rmi o. _ -�-- o (Co late in plicate) y n t v Da ` Issued` �r Applicat on is ere a to the San aquin Lo Healt s for a perm cis' onstru ins a wor ereih a ribed. This application is made in compliance with Cou Ordin n N . 549. ' JOB ADDRESS AND ATION............7� - ---- . ---- ' - Owner's Name-- -- ----/ -------------- •--••- - Phonel-____ Address ------------ l ---•- -- ------- -- --- ---------- ------------------ ----- --- -- . Contractor's Name _........ -•----• •----- --------- ----- .......................................... Phone Installation will serve: Residence,, Apartment House [] Commercial ❑ Trailer Court ❑ Motel ❑ Other Number of living units: ___ Number of bedrooms-Z__ Number of baths ._/-_ Lot size -_---• - _--- 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❑ Clay❑ Adob Hardpan Previous Application Made: Yes E] N New Construction: Yes1 No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public ewer is available within 200 feet. Septic ank: Distance`from nearest well' r�f istance'from founds ion Material =% �C ��= . No.. of compartments.... --------Size- . __�'___� Li uid de th_... 1.. __ . Ca aci ,Q Disposal Field: Distance from nearest well S p � GSD Distance. from foundation__.� Distance to ne�resf"io#/hrte � Number of lines....... .... ......... ........Length of each line___._ _._..------------____.Width of trench_._.- ...................... Type of filter material-------------_---------Depth of filter material_--------------_-----Total length.......................................... Seepage Pit: Distance to nearest well____•------------- Distance from foundation....................Distance to nearest iot"line_................ Number of pits__ _________________Lining material---_-___-__-___._-_____Size: Diameter........ -__...._.._.Depth.__._..._ ._.._..-: -_---.--- 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------------------------------------------ El _______-•-----•------------- ---------❑ Distance to nearest lot line.,. - _ _ ------ Remodeling and/or repairing (describe): r% - ---- ----- -•--- ------ --- ---- ------------- -- ---- ---- ----•-• ---------------- -------- ------- ------- -------- ------ -----•-- ------- - -•- ........ 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 r s d regulations of the San Joaq Local Health District.. (Signed)........... ------ - --------- ------- ---- ------ - - r._..... --------- ----- -- ------- --- ----(Owner and/or Contractor) �r By:------- ------------------------ - --- --•••- .-. ------- ---•----(Title) `;. " (Plot plan, showing ad on reverse s1dg'size of +�tio f in vela von to welts, buildings, etc., can be p ce FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY- -------- --- ---- ------- --------- ----------- DATh t�! ----•-•. ------•........ . ....... ...... REVIEWED BY---------_ -_- - --------------- DATp BUILQING PE IT ISSUED-- ----- DATA - ----------------------......... ..-. rations an / 'r recommendations .0o ... -- ----- r -- �., -- --- - - 7r - ----- - ----- ---- �f --------------- -------------------------------- --- - --- - - •------ ,�"� FINAL INSPECTION BY:.------ --------` Date--------tt- o ----------------------------- SAN --- -------- ------ SAN JOAQUIN LOCAs. HEALTH DISTRICT 130 South Ameriean Street 300 West Oak Street 132 Sytamore Street 814 North 'CV Sfreet Stockton, California Lodi, California Manteca, California -: Traby, California ES-9-2M 8-51 Revised W-2100