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4jc2 �k9P4L1'CqAh6N FOR SANITATION PER MIT Permit No ' � (Complete in Duplicate) ;�l Date Issued Application is hereby made to the San Joaquin Local Health District for a permit to construct and i sta I the work herein described. This application is made in compliance with County Ordinance No. 5 JOB ADDRESS ANY CA ON____---- -�"-- ,� � � :.__ -�. Owner's Name__ � '. - ---•-----v ---- ------- ---------------------------------------------- ------. ------------------------------------------------- Phone__r-2__� (J Address_ --- � r -------- ------•-------- ---------------------------------------------------------------------------------------------- Contractor's Name----------------- ----;�--�"Fr----={- ---� ---- -- ------ __ ----------- Phone Installation will serve: Residenc5�< Apartment House ❑ Commercial F] Trailer Court Number of living units: __ ❑ Motel ❑ Other ❑ - Number of bedrooms..,.-- Number of baths _/---- Lot size ____-_ Water Supply: Public system ---------------- y Community system ❑ Private ❑ Depth to Water Table"_ ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adob Hardpan❑ Previous Application Made: Yes El NoNew Construction: Yes No [l TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if publiW�WoDistance ewer is available within 200 feet.) Septic Tank: Distance from nearest wef from foundation_ __ Y No. of com artments___ ___ Size---�-�' �rl-1Liquid depth--- --Capacity _ Disposal Field: Distance from nearest well------------------Distance from foundation--------------------Distance to nearet loline� ❑ Number of fines-----------------------------------Length of each line------------------------------ C Type of filter material________________ .-_ Depth of filter material-----------------------Width n trench_ Pit: Distance to nearest well Total leng#h------------------------------------------ Seepage C.N >_rf _.__ '_Distance f�,'om'fou{idation______V-----"-_.Distance to nearest lot line _Number of of pits________--________�!fining materi 1_, �!,,_rfL_Size: Diamefier_ -1 '* I r ! Depth---- f�------ Cesspool: Distance from nearest well----- --- Distance from foundation--------------------Lining material______________________________________ ❑ Size: Diameter Depth -----------------Li Liquid Capacity_ Priv q P tY---�-- --------------------gals. Y� Distance from nearest well_ __Distance from nearest build Distance to nearest lot line _ g" ---------------------------------------------------------- ---------------------••--------•----------- Remodeling and/or repairing (describe): -�------------ ------------------------------- Q -----------•--------•-----•-• I- --- -------------------------------------------------------------------------•- ----------------- -----•----------------------------------------------------•----------- ---------------------------------•------------------------------------------------------------------------------- ------------- --------------------------------------------------------------------------------------------------------------•----------------------------------------------•------------------------------- I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, Stat ws, and A and regulations of the San Joaquin Local Health District. (Signed)-------------- s ------------------------------------------------------------------------------------------------------ _(Owner and/ r Contractor) - By:----------------- -------------------------------------------------- ---------- Title (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., canbe placed on` reverse side)?" r FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY REVIEWED BY -------------------------- DATE _1�_----•----------------- -------------- --------- ----------------- ------------------------------------------- DATE------ BUILDING PERMIT ISSUED----------------- ----------------------••---------------- DATE----------qf Alterations and/or recommendations-------------------- -------------- FINAL INSPECTION" BY---------------- @i y -----------•---- Date �. SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South Arnerican Street 300 West Oak Street 132 Sycamore Street 814 North "C" 5}teat Stockton, California Lodi, California Manteca, California Tracy, California ES--9-2M 8-51 Revised W-2100