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APPLICATION FOR SANITATION PERW.T r Permit No.�.-_7 (Complete in Duplicate) Date Issued Applica+ion is hereby made to the San Joaquin Local Health District for a permit to construct and install the work here-in described. This application is made in compliance with County Ordinance No. 55449. / JOB ADDRESS AND LOCATION---------------------- - ------- Owner's Name--------•------------------------------------ ' ------ Phone cS~�r--- Address...............--------------------- Contractor's Name--------------------------------•------------------------ - 1 =--------------•-•-------•--•------------•----------------------- Phone Installation will serve: Residence ❑ Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other p Number of living units: -------- Number of bedrooms -A--- Number of baths --- ---- Lot size ._-_-__-�v------r_14 ___: _ ------•-----------•-- Water Supply: Public system ❑ Community system 0 Private ❑ Depth to Water Table .--%X 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: Yese No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feef.) Septic Tank: Distance from nearest well-----------------Distance from foundation--------------------Material _--_----___--_------_----.-_-.._-_-.-._------ ❑ No. of compartments--------------------------Size.•------------------------------Liquid depth------------ ---------Capacity----------------------- Disposal Field. Distance from nearest well------- Distance from foundation--------------------Distance to nearest lot line----------------- F-1 Number of lines-----------------------------------Length of each line----------------------------- Width of trench Type of filter material-------------------------Depth of filter material-----------------------Total length------------------------------------------ J Seepa a Pit: Distance to nearest weli------ _k_-_ Distance fro foundation �3o'� _ ---- �__-..__.Distance to nearest lot line--_----___-__ Number of pits__------I--- --_------Lining material---_i; --__� : Diameter- *j�_- Depth-._.__,7- a-_ Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material-------------------------------------- F-1Size: Diameter------ -------------------------------Depth---------- ----- Liquid Capacity--------------------------gals. , Privy: Distance from nearest well-------------------------------------------------Distance from nearest building------------------------__ ❑ Distance to nearest lot line------------------- Remodeling and/or repairing (describe)---------- -------------------------------------------------•----------- 3 ---------•---- ---------•-----------------•---•----------------------------------------- -•---••----•-----------------------------------------------•--------•-------------------------------...-•------------------------------------- -------------------------------I------------------------------------I------------------------------------------------------------------------------------------------------ ---------•---------------•----•------------------------------------------------------------------------------------------------------------------------•------------•----------------------------------------- -------------------- I hereby certify that I have prepared this application and that the work will be done in accordance with Sart Joaquin County ordinances, State laws, and rules and regulations of the San Joaquin Local Health District. (Signed)---------------- - ----- -- -------------- - -------------------------------------------- ---------------------------------------- -------(Owner and/or Contractor) By:-- - --- ----'�!'' � - ----- --- •------------------------(Title)-------------------------------------- ------------------------- (Plot plan, showing size of I ocation of system in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY--- ------------- REVIEWED -----------REVIEWED -------------------- -- •-•------------------ DATE---•------------ -••---------�- --------------- BUILDING PERMIT ISSUED --------------------------------------------------------------- DATE-------------- Alterations and/or recommendations-------------------------------------- ----------•--------------------------- -------------------------------------------------------------------------------------------•--------------------------- --------------------------------..-----------------•-•-------------------•--------------- -------------------------- --•-•----------------------------------------------------------------------------------------------------• -------------•----------------------------------------------- ---------------------------- ----•------------------------------------------------._-.--------------------------------------------------------•------------------------------------------- ----- ----------------------------------------------------------- -- FINAL INSPECTION BY: �' -Z G1$1' Date 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-•-9---2M - Revised W-2100