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APPLICATION FOR SANITATION P RMT Permit N0422.11... ® (Complete in Duplicate) Date Issued � Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the wor in described. This application is made in compliance with County Ordinance No. 549, JOB ADDRESS"'AN 0 ATION-__ ____---_- '" 's''�.J -�J- -- Owner's Narr r7----- .t4r -- --------------------------------------------------- Phone_ Address ------ ---•------ ------ e' r Contractor's Name............- ` - ----- ---- Phone------- 1? l�' Installation will serve: Residence Apartment House 0 Commercial Trailer Court Motel 0 Other Number of living units: - j)r___ Number of bedrooms_ _ Number of aths .l_.__. Lot size ____ � _ _ ________ _________ IF 4r 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 lay Loam❑ Clay,❑ ,Adobe❑ Hardpan ❑ Previous Application Mader-Yes [] No New Construction: Yes Gr No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: w (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tank: Distance from nearest well_.__^........... foundation_______.Distance from oundaon....................Material--------------------------------------- P _ j ❑ No. of compartments---- ---- -- --Size--------------------------------Liquid depth -----------Capacity--------- ---- Disposal field: Distance from nearest ell . _.Distance from foundation+ _Distance to nearest lot I Number of lines...... Length of each line 'f"1 ,��rWidfh`of trench « , Ty �._ p �' g T e of filter materials.•___ ___.____. De th of filter material__ 6____-__.-_Tataf ien th__._ ___s -� Seepage Pit: Distance to nearest well----------------------Distance from foundation--------------------Distance to nearest lot line.__.--------- Number : _____Number of pits----_---------------Lining material---_-----------------Size: Diameter-------_---------------Depth-------_..........------------- Cesspool: - -. ----Cesspool: Distance from nearest well_________________Distance from foundation--------------------Lining material._. ____.__ _______.......El ....... Size: Diameter......................--w -----._.Depth....................................--------------Liquid Capacity ---------..............gals. Privy: Distance from nearest well___________ __________ _____ ____ _____Distance from nearest building__,_:__ ............................... ❑ Distance to nearest lot line------ -----•------------------------------------ ----------------• ---------------------------- Remodeling ------- --------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. `� • (Signed) -•---------•--••--•• -- - ---- ----- -- _ (Owner end/or Contractor). BY• sem— ? % ---- ------- - --- --(Title)' --- --- (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse e). FOR DEPAkTMENT USE ONLY APPLICATION ACCEPTED BY __ DATE REVIEWED BY ----- •- -------- DATE '� BUILDING PERMIT ISSUED---------- • - DATE- ,{ - Alter ons and/or recce mendatio t------------ ----- -- _ f r� _ ------ - - --'_-__�_._ Q - , t = w -- . . ---v� S-- ------- ------------------------ --- --- 1� FINAL INSPECTION BY:- - ----------------- tat ---'`5- SAN JOAQUIM LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street132 Sycamore Street 8144torth "C" Street Stockton, California Lodi, California Manteca, California Trocy, California ES-9-2M 8-51 Revised W-2100