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v APPLICATION FOR SANITATION 4ERM`IT Permit No.- G Q ,-- •- _-- . . (Complete in Duplicate) -- -- -----------•• w U Date Issued �•- Application is hereby made to the San Joaquin Local Health District for a permit to construct an in If the work herein described. I` This application is made in compliance with County Ordinance No. 5 9. sic JOB ADDRESS AND LOCAT N------- --------- 1� rj �� -- . � _________________________ -------------------- Address _ _ Owner's Name------�=---•--•-----=- -{� __.--- --�--��.� --•------------ Phone --------------- -- a -t ^E - � Contractor's Name,-----•--------�---------•------ •- -----•--------•- --------------------------• -------- --- Phone----•--------- - ----------• ------ Installation will serve: Residence Apartment House D Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: __1___ Number of bedrooms -3_._ Number of aths .-/__ Lot size ---94 a Water Supply: Publics stem PP Y� y ❑ Community system ❑ Private Depth to Water Table __.___- ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy LoamClay Loam ❑ Clay ❑ Adobe ❑ Hardpan ❑ Previous Application Made: Yes ❑ No �ew Construction: Yes 93-- No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) �R Septic Tank: Distance from nearest well_--- -----•Distance {o� fpu d .i�n__- _____ d �C �� Mat r of ^#1-/L C`a No. of compartments-----; --- - Size--?.".-)F ------ �- _ Liquid death--..�.-- ---------CapacitY--- ------r�---- isposal .field: Distance {nom nearest well__-- U__-Mistance from foundation}_- �Qstance to nearest lot ____ __•--,_- Number of lines_________ _ Len th of each line__ --d_ g ! -.-- Width of trench. ` -_- Type of filter material--- �? r- ------------- Depth of filter material_-__f. -__-.--_Total length-------.�o' _ -------------------- -------------- Seepage Pit; Distance to nearest well----------------------Distance from foundation------------------- Distance to nearest lot line_______-_____., ❑ Number of pits----------------------Lining material------------ Size: Diameter Depth -•-------------- Distance Cess ool: p from nearest well----_--------_---Distance from foundation------------------ Lining material ❑ Size: Diameter-- Depth Priv - rLiquid CapacitY----------------------------gals ? Y� Distance prom nearest well-----------------------------------------------__Distance from nearest building--:--- -"""" " ❑ Distance to nearest lot line-------- --------- g"" ------------------------------------I --------------------- i -------- Remodeling and/or repairing (describe)------------------------------------------------------- --•-----•---•--•-•-------------------•----------------- I ---------------- --------------------- -------------------------------•---•---------------------•-- I hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State s nd rules and regula ions of WeRSain Joaquin Local Health District. (Signed)---- BY: 7- tVEF�—— _______________(Owner and/or Contractor) ----•--- ----•• ----- - -------------------------------------------------------------- (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). ----(Title)---------- ARTMENT USE NLY APPLICATION ACCEPTED BY------ ---- ---- ---- DATE l REVIEWED BY------------------------------- - -- - ------- ------------------------------ ------ DATE---- BUILb1NG PERMIT ISSUED-------------------- -- --------------- ---------=----------- ------------------------------------------- -----------. DATE---------------- ----------- A ---------------------- Alterations and/or recommendations- �-�------ ------- �----�---- ---- FINAL INSPECTION BY:------ --_ Date - -------------------------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Street 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California 4ES-9-2M JO-52 Revised W-21o0