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VAIA 410'11::1, APPLICATION .FOR SANITATION P Permit No `o RMiT .crZ ------------------ ^ + i1 (Complefe in Duplicate} ` Date Issued Application is hereby made to the San Joaquin Lo al Health District for a permit to construct and install the work herein descri ed. This application is made in compliance with County Ordinance No. 549. JOB ADDRESS AND LOCATION.- ! — --- Owner's Name /J ter . - - --- - ---- ----------- - - ----- Ph6n -- ------------------------ --------------- -- Address----- - •. Contractor's Name......... r'�= -' Phone �7 Installation will serve: Residence' Apartment House ❑ CommercialA Trailer Court ❑ Motel E❑ Other ❑ Number of living units: _/---- Number of bedrooms I---- Number of baths I___ Lot size ______�.k��oO Water Supply: Public system �'` Community system ❑ Private ❑ Depth to Water Table..------- ft. Character.of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobelk Hardpan ❑V.-.1., Previous Application Made: Yes ❑ Noy New Construction: Yes ❑ No� �y► + TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sower is available within 200 feet.) Septic Distance from nearest well----- ____Distance from foundation---------------------MateriaL__-_-____.__________.._-_ ____________._____. v� No, of compartments--------------------------Size---------------- ---------------Liquid depth--------------------------Capacity---•------------------- Disposal,4; Distance from nearest well___ Distance from foundation--------------------Distance to nearest lot.lme----------------- QNumber of lines -----------------`--------------Length of each line------------------------------Width of trench----------- Type of filter materia!__________________ ____Depth of filter material-------------------_._Total length............................................ __ Seepage Pi}: Distance to nearest well-- -----,_;Distance from fou dation___-Z _____-Distance to nearest lot lin r__ - r Number of pits-------/_____________Lining materia! _ Size: Diameter_ f - -____-____._----- -.Depth-----o� --------------------• 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------------------- ___._________1�_-_. ❑ Distance to nearest lot line------------------------ o rn `[descrRem / >e)----- - ------•------------ , _ l -P� ------------ --•--- :__-_-- _ _ v - - ------- ---- --- -----•------- -----v •- --- -^� - ----------- '1 - --------------------•--------------------------------..._ ---------------------------------------------•-------------•---: -------==--------•------------------------• -------------•------------------------------- � I hereby certify that I have prepared this application Lnd that the work will be done in accordance with San Joaquin County ordinances, St to laws, and rules and regulations of the San-,Joaquin Local Health Distric+. (Signed)- = --------._ ~---------------------------------------------------------------------------- ---------(Owner and/or. Contractor) �� Ti+le._ -t- --- _.�----------------------------------------------- (Plot plan, showing siz of , location of system in`�relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY---------- DATE----- ------------------- - - ---------------------------- r REVIEWED BY ---- - -Y+ _ _ DATE------ / 0 �;. .� BUILDING PERMIT ISSUED ---- ---------- DATE Alterations and/or recommendations: ------------------------------------------------------------------------------------------------------------------------------------ ---------- ------------------------------------------------------------------------------------------------- ---------------------------------------------------------------------------------------------•--------------------•----------•------------------------ ---------•---------------------------------------------------------------- ------------------- S FINAL INSPECTION BY: / ---------------------- Date------ SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 Wast Oak Sfreef 132 Sycamore Sheet Y 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California ES-9-2M B-51 Revised W-2100 1