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S APPLICATION FOR SANITATION P Permit No _--- d L PERMIT (Complete in Duplicate) ,, Date Isrrued ---3-75-7.5-Yr✓ Applica-'ion is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described. This application is made in compliance with County Ordinance No. 549. JOB ADDRESS AND LOCATION------- -----------------3 sS- &�,j Vt_-dJ_? Name----------------------- )� - ----------- ------ Phone----•------------------------------- Address---------------------------------------•-----•---------- Contractor's Name-------------------- Phone Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel P Other ❑ Number of living units: ___-____ Number of bedrooms --a-- Number of baths -------- Lot size ----------73__,er_/2_a-°------------------ Water Supply: Public system ,r Community system ❑ Private ❑ Depth to Water Table -------- ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam [] Clay ❑ Adobef�' Hardpan ❑ Previous Application Made: Yes E] Previous New Construction: Yes, ] No F-1 "/ TYPE OF INSTALLATION AND SPECIFICATIONS: 44 (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tank: Distance from nearest we}I--_-A40---__ Distance from found tion_---/-_ ��1� p - - �--------.Material-------�`^-�':- -----•------------------------ No, of compartments------.---- ___-:_-__Size----__ - --!F--a.Liquid depth-----------413- Capacity----_T_ -50 f f Disposal Field: Distance from nearest weft- �. .-.-Distance from foundatiFFn--------------------Distance to nearest lot line.--_�-_-.-_- Number of lines---------------.�---------:T---Length of each line---C? �` r�X �__-Width of trench----___- -----------•--- Type of filter material------ ------Depth of filter material-------_/f_f_------Total length--------- ---- - ----_--_--_------ Seepage Pit: Distance to nearest well----------------------Distance from foundation-------------------.Distance to nearest lot line-------_---_---_ ❑ Number of pits----------------------Lining material-----------------------Size: Diameter---------------------- Depth-------------------------------- i Cesspool: Distance from nearest well-----------------Distance from foundation___-----------------Lining material------__---------------__-----_----_. ❑ Size: Diameter--------------------------------------Depth----------------------------------------------------Liquid Capacity----------------------------gals__ Privy: Distance from nearest well-------------------------------------------------Distance from nearest building------------------------------------------ F-1 Distance to nearest lot line------ ------------------------------------------------------•-------------------------------------------------------------------------------- Remodelingand/or repairing Idescribe):--------------------------------------------------------------••-------------------------------• --•--------------------------------------------•-------- -------------------------------------------------------------------------------------------------•------------------------•----------------------------------------------•----•-------------------------------- - I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State laws, and rules and regulations of the San Joaquin Local Health District, (Signed)...----- ------------------- --------------------------------------------------------------------------------------------------------------(Owner and/or Contractor) % - Y- ------------- ----------------------------------------------------------------------------------------(Title)------------------------------------------------------------- (Plot pian, 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------------ -----•----- BUILDINGPERMIT ISSUED---------•---------------------------------------------------------------------------------------•--- DATE-- ------------------------------------- Alterations and/or recommendations:--------------------------------- ---------------------_---_-------------------------•------------------•----- -----------------------------------•---------------------------------------------------------------- ------- -------------------------------------•-•-----•-------------•---------------•------------•----------------------- ------------------•----------------------------------•-----------------------------------------------------------•--•- --------------------------------------------••-- -•------------------------------------------------- -----•---------------------------------•---------------•---------------------------------------------------------------------------------------------------------------------------------------.------------------------------ FINAL INSPECTION BY---------------- - ------------------------- •----- ------------- Date SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Stree+ 300 Wes+ Oafs Street 132 Sycamore Street 814 North "C" Street Stock+on, California Lodi, California Manteca, California Tracy, California ES-9-2M Revised W-2100