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APPLICATION FOR SANITATION PEM Permit NoQi_7� --- (Complete in Duplicate) 7 Date Issued _ ____9_ _� -- Application 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_____ Owner's Name - , 'L----- - ---- ---- ------- -------------------------------- Phone Address-------- 1 _ -- - _ -- --- --------------------------------------------------------------•-------------------- Contractor's Name ll r �1 -CS C----------- Phone �h--�� -------- Installation will serve: Residence Apartment House E❑ Commercial ❑ Trailer Court ❑ /Motel ❑ Other El Number of living units:__ umber of bedrooms-&---.Number of baths /_____ Lot size ----Zo cr -/AD------------------- Wafer Supply: Public system VCommunity system ❑ Private ❑ Depth to Water Table Characfer of soil to a depth of 3 feet: Sand ravel ❑ Sandy Loam ❑ y Loam ❑ Clay ❑ Adobe Hardpan ❑ Previous Application Made: Yes ❑ No New Construction: Yes kN, ❑ 4 ' TYPE OF INSTALLATION AND SPECIFICATIONS: (� (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Ta k: Distance from nearest well G / Distance from foundation-_ __ -------Mater/I----- - ---- - -�---• � No. of compartments--__ -----�_ /----Si e----�4F,r�----Liquid depth.----- --- �,----Capacity----- !�0---- Disposal Fi d: Distance from nearest well��7_;Q I�-�Uistance from foundafion_�_d,______-/d, -Distance to nearest lot line_��_'______.___. Number of lines-------_._____ _ ___-____Length of each line---- r1 ___`�-��___.Width of.french- Type of filter material__�_�- e---Depth of filter material__1_k---- g ' -----Total len th------�-- �------ ----------- Seepage Pit: Distance to nearest well----------------------Distance from foundation----------------.._.Distance to nearest lot ii6e______________.__ ❑ Number of pits----------------------Lining material-----------------------Size: Diameter-----------------------Depth--------------------------------- Cesspool: --------- ------`- - ----------- Cesspool: Distance from nearest we1l-----------------Distance from foundation--------------------Lining material-------------------------------------- F Size: Diameter--------------------------------------Depth----------------------------------------------------Liquid Capacity-----_ ----------------gals.. Privy: Distance from nearest well-------------------------------------------------Distance from nearest building______--_-_______--______-___ 171 Distance to nearest lot line--------------------------------------------------------------- Remodeling and/or repairing (describe)_________________________ ---------- _ --••---------------------------------------------------------------------•----------•-------�------•-------------------------- ------- ---------------------------------------------------------------- --------------------------------------------------------- ----•---------------------------------------------------------------------------------------- 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 d rules and regulations f the San Joa uin Local Health Di icf. (Signed) - - ------ i�. {Owner d/or ntracfor] By:------------- ------- ----------- �'---------- ---{Title 1 04 � =_1 (Plot plan, showing size of lot, location of system in relation to wells, buildings, efc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY- ------------ DATE��----------------------------------------------------- L REVIEWED BY_ --------------------- ---- -- ----------------------------------------------- -- -------------------- -------• DATE_- S ------------------------------ BUILDING PERMIT 1S UED--------------------------------------------------------------- --------------------------------------- DATE_----QCT -------------------------------- Alterations and/or recommendations:___-__.._-__- __---- ------------------------------------------------------------------------------------------------------------•----------------------------------------- ------------------------------------------------------------------------ --------------------------------------------------------- _ i 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 s ES-9-2M 8-51 Revised W-2f00