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APPLICATION FOR SANITATIO PN ERMITPermi (Complete in Duplicate) at Ir u - Application'is hereby made to the San Joaquin Local Health District for a permit to construct and install the worLal e scribed. This application is made in compliance with County Ordinance jNo. 54F. JOB ADDRESS AND LOCATrINS = Owner's Name ---- Phone---------------------- -------- ' "`..y Address.......----------------- ---- - ---- -- �----- -- - .. j Contractor's Name_- �: �_ d Phone- L7 Installation will serve: Residence Apartment House ❑ Commercial ❑: Trailer Curt ❑ Motel Other ❑ Number of living units: ------ umber of bedrooms _______ Numbe'.of.ba ----------Lot size7�___________._ Water Supply: Public system Community system ❑ Private ❑ tepth...I_Wate'r Table ________ ft. Character of soil to a depth of 3 feet: Sand ❑3� Gravel E] Sandy Loam ,-Cla Loam ❑ Clay E] Adobe Hardpan ❑ , Previous Application Made: Yes E] No E] New Construction: Yes No E] TYPE OF INSTALLATION AND SPECIFICATIONS: l NN, (No septic tank or cesspool permitted if public sewer1s available within 200 feet.) �y Septic Tanks _ Distance from nearest well-----------------Distance from foundation___,_______-_____.Material___----------------___________________________ f 4/� No. of compartments--------------------------Size+ r'�'"�---------------jLiquid depth--=------------------------ Disposal -------------------:_CapacitY f Dis osal F' Distance from neares well_�'�Distance fro, foundat.io 0 p ,_-__ �. �.� ______._Distance to nearest I �linet�______.___. l Number of lines______�s Length of]each line_____ •' Width of french_ ______ s or Type of filter materials_ - _f___Depth of�filter material_____S- $- _Total length___ __ s --------------------------- g See a it: Distance to nears well__ ' ___ r # 'xline. p g ____-_Distance rcrqun ation_____ (�________.Dis ��e #o nearest lot ,,.___-__________ Number of pits__ __ _ _________Lining material_ _P __`��' Size: Diameter___ --_______-Depth----�,��•____________--__ r r^ Cesspool: Distance from nearest well________________Distance from foundation--- _____ '_'----- Lining material_____________________________________ ❑ Size: Diameter------------------------------------- Depth----- ----I------------------ ---- ---------Liquid Capacity----------------------------gals. Privy: Distance from nearest well-------------------------------------- ____ m nearest building r ---- g--------------------------------------- ❑ o nearest lot line--------------- ---- -----_----------- Dist ce ro n Distance t Remodeling and/or repairing"(describe):-- -----_-----------------------------------------i f --------------•-•----•---------------- ----------------------------------- i [ t ------------- - -- --- ------------------ -- -- - -- ------- ---------------------------------- ----- ---------------------- -- ---•---------------- ----------------------------- a 1; I hereby certify that I have-prepared this application and that the'work will Wdorie'in accordance with San Joaquin County. ordinances, State la s, and rules anA regulations of th San oaquin Local H -alt�h District. (Signed] ; {Owns '�` dor Aractor] B ----� t ------------------------ !-------- - � A- Title y a� ( ] �' = (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 _ DATE .. -- :: -------- -- BUILDING PERMIT ISSUED--- ------ ----- -----------/----�--- --- ----------------------- DATE Alterations and/or recommendations-------------------------------------------------------------------------------------------------------------------•--------------------------------------- ••- ---------------------------•------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------------------------------- -------------------------------------------------•------------=----------- -------------- --------------------------------r--------------------------------------------------------------------------------------------- ----------------------------------------=---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- y FINAL INSPECTION BY:_---:A)---V__ ------------------------------- Date------3---------- k 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 B-51 Revised W-2100