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-� APPLICATION FORII,SANITATION PERMIT Permit N5—, __b7j 1 3M1 (Complete in Duplicate) 6 ' Date Issued u Application is hereby made to the San Joaquin Local Health District for a permit to construct and install t i� d• This application is made in compliance with County Ordinance No. 549. JOB ADDRESS AND LOCATION_975 --------------- --- 6 1 1'J ? l ------------------------------ - e� Owner's Name----•�-A---•;-- --= --------- Phone-- Address =-t ` ��S' .-Tc'.�'f fid`! ----- Contractor's Name--- ----�FL%AA!e=----------------------------I---------------------------------------------------------------------- --------------- Prone--------f`------------------------ Installation will serve: Residence © Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel d Other ❑ Number of living units: ________ Number of bedrooms __K__ Number of baths _?____ Lot size ------ __________________________ Water Supply: Public system R Community system ElPrivate ❑ 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 0 New Construction: Yes ® No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) OC1 Septic Tank: Distance from nearest- well_____ ------Distance from foundation_ ------- -- --------Materia l V ® No. of compartments----------•2------------Size---=-�� X Y -------Liquid depth-------- t ---------Capacity ---g'b ` •. Disposal Field: Distance from nearest well------C-J-----Distance from foundation_____ _K'_ -------Distance to nearest lot line_____________ Number of lines----------� ----------------------Length of each line_______G-4?----------------Width of french------- ----------- Type of filter material-------------------------Depfha of filter material----------------------Total length-------_---------------------------------- Seepage Pit: Distance to nearest well--.-------------------Distance from foundation--------------------Distance to nearest lot line--_.----________ ❑ Number of pits----------------------Lining material:---------------------- Diameter---------------------- Depth--------------------------------- Cesspool: Distance from nearest weld-----------------Distance from foundation--------------------Lining material-_____--____.------__________________. F ❑ Size: Diameter-------------------------- -----------Depth-, -------------------------------------------------Liquid Capacity-:--------------------------gals. Privy: Distance .from nearest well_.___.____________________ ----------.-------- Distance from nearest building------------------------------------------ ElDistance to nearesf lot line--=--- - -�.- --^- --- - ---------------------------- -- ------ --------- ------------------------- Remodeling and/or repairing (describe)---------------------- ---------- ------ - - - �,,. �----------------------- -----------------------•--------------•-------------------------------------••-----------------------------'f------------------'-----------------------I--------------------------------------------------------------`------ -------- ------------------------------------------------------------------------------ --------------------------•----------------- --------------------------------------------------------- - ---------------------------------------------------------- ---------------------------------------------- ------ ----------------------------------------------------------------------------------------- - I hereby certify that I have prepared this application andAat the work will be done in accordance with San Joaquin County ordinances, Sfalp laws, and rules wi regulations of the San Joaquin Local Health District. -. (Signed}----- �''t� l- �' - -------------(Owner and/or Contractor) By:----------------------------------•-----------------------------------------------------------------------------------------------(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---- REVIEWEDBY--------------------------------------------- ----------------------- DATE--.-- --------BUILDING PERMIT ISSUED-----------------------------------------------------------=---------------------------------------- DATE------------------------------------------------------------- Alterationsand/or recommendations----------------------- ---------------------s------------------------------------------------------•---------------------------------------------------------- --------------------------------- --- ------------------------ ------------------------------------------- -------------------------------------------------------------------•--•---------------------------------•---------- _______________________________________________________________________________________ ______.__-___-_________._-__.___________-.---_-___________._____.____________________-.___..._-______--_________ ii FINAL INSPECTION BY------------------------------------`--- - ------- --- Date-----------C.' 1 SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Sfreet 300 West Oak Street 132 Sycamore Street `814 North "C" Street Stockton, California Lodi, California Manteca, California . Tracy, California ES-4-2M 8-51 Revised W-2100