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` APPLICATION FOR 5 II/ t SANITATION PERMIT P 3 dl (Complete in Duplicate) `� Date Issued-"�""�[_-5_-��' Application is hereby made to the San Joaquin Local Health District r This application is made in compliance with County Ordinance No. 549r a permit to construct and install the work he described. JOB ADDRESS AND LOCATI ---.-----_ ,1 " ' ------ -- - -- -- _ -----" Owner's Name-----•--• - ----------•----- -------- ---- 'J ----- Phone---IF---- _ Address ------�� - ------ xr►ter^--��- i -------•------------------•--------- = --------- ---------------------------------- ------------Contractor's Name______ _ d.�.s� _ " - '-------•--------------------------- ------------------------------I- ------ Phone---- ----- ----•--- ----•------• Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Mote! ❑ Other ❑ ', Number of living units: - ----- Number of bedrooms _2_ Number of baths ____-___ Lot size Water Supply: Public system Community system stem ❑ Private ❑ Depth to Water Table—f0 {}- Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adob Hardpan ❑ Previous Application Made: Yes ❑ No-° New Construction: Yes ❑ No w 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 _____.Ma+erial____._._____"----------------------------------- ------------- --__.___"_______" X "I I /V No. of compartments --------------- Size. Liquid depth- -------------Capacity------ --------------- Disposal Field: Distance from nearest well________________Distance from foundation-------------------- �� Distance to nearest lot .� Number of lines----------------------------------Length of each line----------------------------- Width of french------------"__"-- Type of filter material__________.___"_ -------Depth of filter material_______-_ Total length_ ------------------------ Seepa e Pit: Distance to nearest well�Lining Distance m fo ndation___-�-_ --.Distance to nearest lot line_:__. "i��umber of pits_____._.____ material_ -----Size: Diameter__._�-""__." ----- Depth------ 0 esEJ spool: Distance from nearest well-----------------Distance from foundation-------------------.Lining material_.._____"_______...____.__---------- Privy: Distance from nearest well - Size: Diameter--------------------- ---- -------- Depth -----•--- ----- Distance"to nearest,fot line________ ---------- ---------- ------Liquid Capacity---------------------------.gals. ____ "_____._____"_____.____ __ -"Distance from nearest building------------------------------------------ " ------------------------------------------------ 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 iaw , anrowl . ,�gulatioris of a San Joaquin Local Health District. (Signed)--------------- --•• �� ---- ' ------------------------------------------------------------------------------- - { wner and or-Contractor) BY� ------------ -- r. - - (Title)---= (Plot plan, showing size ofn of system in relation to wells, buildings, etc., can be pla on reverse side). FOR DEPARTMENT USE: ONLY APPLICATION ACCEPTED BY�._____ REVIEWED BY �r DATE_- ------------------------------------------------------------------------------- DATE BUILDING PERMIT ISSUED---- .r-"` --------------------------------- terafions and/or recommendafions:__.___.--------------- --- ------------------------------------------------------------------------------------------------------------------------------------ ------------------------------------------------- DATE----- _QUA ----------------- --------------- ------------ --------------------------------------------------------------------- FINAL --------------------------- •- FINAL INSPECTION BY:........ ` Date (5 's SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Sfr3ef,. Stockton, California 814 North "C" Street Lodi, California Manteca, California Tracy, California ES-9-2M 10-52 Revised W-2100