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APPLICATION FOR SANITAT PE MIT r Permit No- ------ -------------- i ' (Complete in Duplicate) l S Date Issded _/ � V I Application is hereby.made to the San Joaquin Local Health District fora =ermit to construct and install the work herein described. This application is made in compliance with County Ordinance No. 549.// e -----------------------------------------------------r --------- JOB ADDRESS ANp.L T10 ----- - s Owner`s Name__ __ __ a Phone- ----- l Address--- _ - --------------------,-------------------------•--•--------•--------------------------------------- -- `--�----------- --- --------------------------- ---------------- Contractor's Name----------- ----- - -------------------------------- --------------------------------------------- f Installation will serve: Residence Apartment House El Commercial ❑ Trailer Court [I -Motel ❑ /Other ❑ Number of living units: -__ Number of bedrooms _Number of baths __J__. Lot size -- { "��------------------------ _ — W.Water Supply: Public system Community system ❑ Private ❑ Depth to Water Table _ �� ft. g Character of-soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam [I Clay Loam-❑ Clay ElAdob�e,�" Hardpan E] Previous Application Made: Yes ❑ NoX New Construction: Yes ❑ No TYPE OF INSTALLATION AND SPECIFICATIONS- (No septic tank or cesspool permitted if public sewer is available within 200 feet.) e from nearest well_________________Distance from foundation___________._____.Material____--_._-______--___________-_-_____________--- Septic Tank: Distanc� No. of compartments--------------------------Size------------- ----------------- Liquid depth------------------------- Capacity.._ � Disposal Fiel -. _ Distance from nearest well-----------------.Distance from foundation--------------------Distance to nearest lot line----------------- r}. Ij�r C� Number of lines------------------------------------Length of each line------------------------------Width of trench----------------------------------- (` V Type of filter material_____________________ _Depth of filter material-----------------------Total length_____________-------_------------ ----- 1 Seepage Pit: Distance to nearest /well -_ _Distance fr m fou ation___ ----------- to nearest lot Gne_ ------- Number of pits_------/_---------- ining materialiSize: iometer-- -+-_--____-Depth----_____f��---------- �" Distance from foundation____________________Lining material_____.____-____._____-____________- Cesspool: Distance from nearest well____________ f Size: Diameter-------------------- ................. --------- -----Depth----------------------------------------------------Liquid Capacity----------_•------- gals. �I Privy: s Distance from nearest well---------------------------------------- ------Distance from nearest building----------------------------------------- Privy: Distance to nearest lot lire------------------------ G --------------------------- -•-------------------------- Remodeling and/or repairing (describe):----------� ---)/0- -------------------------------- ------------------------ --------"------------------------------------- -------------------------------------------------------- -------------------------------------------------------------•- - =--------------------------------------------=----------- ------------------------------------------------------••------------------------------------------------- I hereby certify that I have,prepared t ' appli ation and that thework will bed a in accordance with San Joaquin County ordinances, State and r . s-,nd regul tions t San Jo uin Lo -Health rict. ' -(Owner and/or Contractor) (Signed]. _ t ". _ _ _ _ -----------------------------------------------------------._____________ _________ ___ __ ----------- By- ____._____ gY:-=-----•--- -----(Tit e)------ 1--- - - (Plot plan, showi size of`Iot, Iocatio of system in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED.BY------------- ----- DATE /�3: ;�` `. -- ----------------------------------------------------------------- REVIEWED BY----------------------------------------------- --------------------------- DATE-------------------------------------=--------------------- BUILDINGPERMIT ISSUED--------------------------------------------------------------- -------------------------------- DATE -- Alterations and/or recommendations-------- -------------- ------------•--------------------------------------------------------- -------- ------------------------- -------------------- --------------------------------------------------------- FINAL ----------------------------------FINAL INSPECTION BY: + _ Date - �'------------ - i �t 4 SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Street 814 North "C"Sfreet Stockton, California Lodi, California Manteca, California Tracy, California ES-9-2M 8-51 Revised W-2100