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`APPLICATION `POR SANITATION PERMIT Permit,.No. .___...`.'..G:'.......' (Complete in Duplicate) / .��.. � Date Issued Applicationis'hereby made to the San Joaquin Local Health District for a permit o construct and install the work herein described. This-application is made in compliance with County O4nce No. 5 k • JOB ADDRESS AND LOCATI N--- —-•-- ... ��----------------------•----------------------------------------Owner's Name- ' -------- Phone--- --------G}- iAddress---- - - --------------- -------------------...---------•-------------------------------------------------------•-••-------..._..----------- Contractor's Name------ f r'" r------------------------------------•---------------------------- Phone l Installation will serve: Residence' Apart ent House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: _f--__ Number of bedrooms__ Number of baths ---/--- Lot size __-&,9 .----------------------- Water Supply: Public system Community system ❑ Private ❑ Depth to Water Table.�Qft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adow Hardpan L❑ Previous Application Made: fYes E] No New Construction: Yes ❑ No \` TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) [ Septic Tank: Distance from nearest well________________Distance from foundation__.______________-_.Material----------------__.._ ; No. of compartments--------------------------Size-----•-•--------------------•---Liquid depth---------- ----- ---------Capacity---------------=------- k Disposal Field:-..; , Distance from nearest well-----------------Distance from foundation--------------------Distance to nearest lot line______.______.___ Number of lines-----------------------------------Length of each line---------------------------.-.Width oftrench----------------------------------- �J►� 1 `J Type of filter material_,______________________Depth of filter material------------------------ length______________________-______-__ ., , . v _ -- �-,� Seepage Pit: Distance to nearest well__ _. . Distance f -m-fou,dation__ �._______.Dista i e to nearest lot line________________ T- Number of pits-----_/_____________Lining material_ _ __.__.__ ! __Size: Diameter__..___----------Dept h__._-_- Ces"spool: Distance from nearest well------------------Distance from foundation--------------------Lining material--------------------.-------_.__---_ Size: Diameter--- '------------ --------------------De th------------------------------------ - -------------Liquid Capacity-.. gals. { Privy: Distance from nearest well-----___-----------------------------------------Distance from nearest building--------------__----------._______..____- I ❑ Distance to nearest lot line--; ------------------ --------------- --------------- i _ .____ ___1____---------_______________________________________________________________________•____________________________________ Remodeling and/or repairing[describe):__-__ Q ------------------------------------- ----- --------------------------- ••-------------------•------------------------------------------ --- .. -----------------------------------•-------------- -------•-------------------------------•-•------------------------------------------------------------------------- ----------------•----------------------------------- I hereby certify,that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, S:V4 ws; a r les and regulations of the San Joaquin Local Health District. (Signed)--------- _.. - -j_._____ (Owner and/or Contractor) By:. /- - ..... ,�' '! --'---------------------------------- ----------------------------- (Title) Aed _.[Plot plan, showing ' e �f lot, loc�ion of system in relation to wells, buildings, etc., can beds rev�e si . i- FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY _ -�------------•---------------------------- DATE------------------ r- -------------------------- ' REVIEWED BY--------------------------------------------- --------------------------------- DATE f 1-*"'' BUILDINGPERMIT ISSUED-------------------------------------- - ----------------------------------------------------- DATE-------------------------------------------------------------- Alterations and/or recommendations:-------------- --- ---------------------------•------------------------•---------------------------------------- -----------------------------------------------------------------------------------------••------------------------------------ -------------------• ------------------------------------------------------------------------------•------------------•-----------------------------------------------------•------------------------------------------------ •----•----------------•-----------------------•--------------------------------------------------------I--------------------------------------------------------------------------------------------------------------------- --------------------------------- FINALINSPECTION BY----------------`--±--•---------- -------- ---------------------- Date---------------------- --------------------------------------------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 Wast Oak Street 132 Sycamore Street 814 North "C" Street Stockton, CaCfornia Lodi, California Manteca, California Tracy, California ES-9-2M 10-52 Revised W-2100