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. APPLICATION F . OR SANITATION PERMIT Permit No. __-J�__� �__�-_ -(Complete in Duplicate) '" — -Date Issued Application is hereby made to the San Joaquin Local Health District for a permit to Construct and install hwork herelr&describeQkr__ This application is made in compliance with ounty Ordi nce No. 549. I R. JOB ADDRESS AND LSC Tl Y_ -- Owner's Na - ------ ------------- ----------------------- =------------------------- -- ----------- - -- Address-____ -- _-.i�_�•.- - --------------------- Phone Contractor's Name ____________________•__._-______-- ----------------------------------------------------- Phone------------•---------------------- Installation will serve: Residence ❑ Apartme House Commerc ❑ ail r Court ❑ Motel ❑ Other [] Number of living units: A0__ Number of bedrooms ---6- Number o Lot size 30_0 )-670 -- Water Supply: .Public system E] Community system ❑ PrivateK Depth to Water Table - - ft. Character of soil to a depth of 3 feet: Sand IV Gravel p Sandy Loam ❑ Clay Loam a I ❑ Clay ❑ Adobe❑ Hardpan ❑ f� Previous Application Made: Yes ❑'4No K New Construction: Yes No ❑ f ill ! YPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if ublic sewer is available within 200 feet.) I Septic Tank$" Distance from nearest well_ Q---Distance from foun n---- -_-_ f 1 No. of compartments '.Mat . is - -------- y__ ----- , Size-- _ _ euid dep}h ' Capacity- -�- - - - f Disposal Field Distance from nearest well___ ' r� --Distance from foundatio ---- 18- ante to nearest lot line-.� . Number of lines_--ems--_ _ s �_ Length of each line- 55- Type of trench-_,_ Type of filter material__-. ____ -- i�- � '�Depfh of filter material---- -2_.��-_Total length------I- ___0 -------------------- �MF_1 ` Seepage Pit - Distance to nearest well -------------Distance from foundation--------------------Distance to nearest lot line-------_--__--- Number of pits______________________Lining material____---_---__--__-_---Size: Diameter_-_-,---____------__ - Depth------------------------------- Size, -------- - •- Cesspool: Distance from nearest well_-_-----_--. Distance from foundation------------------- ❑ Size: Diameter------t------------------------- ----Depth--------------------------- �d aerial ------------- Lining material Priv -----------------Li u' Capacity------------------ ----__-__--_----__-----Distance from nee"rest b ildin '� ��"�^`=tet ------------------------------------ ElDisfiance topnearestelot lime-__-_--'_ ------•----------------------------------------- Remod ing ander repair' describe :_-----_ -------------------- ----- --- ---�► .. - -' --------•----------- -------------------------------------- ---------------------------------------------------------------------------------------- I � � ------------- - -- •-------------------•--------------------------------------------------------------------------------------------- I�' I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State,.1 4''s, and rules and egulations of the San Joa juin Loc,4 Health District. (Signed)----------- 0 " ` ------------------------------------------ (Owner and/or Contrac -(O --ori ------------------- -- --------- -------------------- ---------------------(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------- - ------- REVIEWED BY - ----•------------------------------- -- ---- - BUtILD1NG PERMIT ISSUED DATE ----- - s --------•---------- II / ------.DATE------------------ ------- Altera+ions and/or recommendations•------------- ------------- -- ---- --------- ------ ------------------ - •-Iii----•- --•----••------- ------------------ =_ -----•-----------•----------------------------------------------------------- ---------------------- ------------------- -------------------------- -----=----------- ---------------------•--------------•----•--•---•-- - --------------------- l - FINAL INSPECTION BY-------------- Date - SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Street Stockton, California 814 North "C" Street 1 Lodi, California Manteca, California Tracy California ES-9--2M 8-51 Revised W-2100 i1�1