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PLIC TION F SANITATIO PERMITPe'rmit o Q_ •. (Cam to in Duplicate) Date Issued . est► Application is hereb -made to the San Joaquin Local H alth District for a permit to construct and install the work herein described. This application is made in compliance with County Ordinance No. 549. til-?T "_ J B ADDRESS AND CATION_ -. 4-- f - - ---- Owner's Name_ Phone -------------- Address------ Contractor's Name____________ ____ �_f -------------------------------------------.-------- Phone__ _----- �� Installation will serve: Residence Apartment He Commercial ❑ Trailer Court ❑ Motel ❑ Other E]Number of living units: _._ __ Number of bedrooms _ - Number of baths __ _____ Lot size __ ¢.'. .,,.__---_- Water Supply: Public system ❑ Community system ❑ Privat�,W Depth to Water Table ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam Clay ❑ Adobe❑ Hardpan [' Previous Application Made: Yes ❑ No New Construction: Yes ❑ No f 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___�_�_--___-Mater ial__. z:f ::__4 -- 'Exu / q No. of compartments------- -----------------Size_.__�j._ �G-------Liquid depth-------------------------Capacity--------------------- Disposal ----Disposal Rel . Distance from nearest well-----46-e from foundation_-_____________....Distance to nearest lot line----------- ,4;7//Y Number of lines-----------------------------------Length of each line-----------------------------.Width of trench V ' Type of fitter material---- __Depth of filter material----_----------------__Total length______,____________._________________.__ Seepage Pit: Distance to nearest Weil_ _ __0� ____Distance f m fo dation--_ _ -- ��__._____.Dis#ince to nearest lot line__._____ Number of pits 1 ming materia -1- -Size: Diameter---,?--_-- Depth ------- ------ -�--- - - - ---------- l-1 Cesspool: Distance from nearest well-----------_-----Distance from foundation---.-----___--------Lining material------------------------------____- �1 ❑ Size: Diameter------------------------- -----------Depth----------•---------------------------------------Liquid Capacity ------------- -----------gals. I Privy: Distance from nearest well_____________________ ___________--------------Distance from nearest building ❑ 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, Statefzfw-s, and I nd regu�!3T ' of the San Joaquin Local Health District. L ---- ---f-- - Rc' c---'---------- -------------------- -{Owner...artd/or Contractor(Signed}_ _ _ � , By:--------- --- dr (Title) ----------------------------- ---•---------------•------------------ Pot plan, showing si a of lot, location of system in relation to wells, buildings, etc., can be p d on reverse side FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY_ ------------------------------------------------ -- DATE-.7- --- t------------• ------------------------------------- REVIEWED BY----- --------------------------- ----------------------------------------------------------------------------- DATE---;0a,. . -------- BUILDING PERMIJ ISSUED--------------- ------------------------------------------- A .erations;�nDATE . �tft ------------------ ------ i,------ � _ : :-' ' - r -- - ------------•-------------------------------------------- ." ------ -- ------------------- --------------------f- FINAL INSPECTION BY:---- 'r�___-- 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 ES-4-2M r0-52 Revised W-2100