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APPLICATION _F(-_. SANITATION PERMIT Permit No. ...... 4-._.... omplete in Duplicate) Date Issued __-.. __y ___ T"Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described. 4)is application is made in compliance with County Ordinance No. 549. .JOB ADDRESS AND LOCATION_____._____ Owner's Name------ �� aR./ Pho f, Add ,� ress__.16 _ _ ^�- ---------------•--------_------- Contractor's Name___________ ____ __p------------ Phone _- --------------------------------------------- --- Installation will serve: Residence Apartmen�ouse ❑ Commercial ❑ Trailer Court ❑ Motel Other ElNumber of living units: __ Number of bedrooms-- Number of baths ._/--_- Lot size _ --------------------------- Water Supply: Public system Community system ❑ Private ❑ Depth to Water Table 0_1Y)ft. ' Character of soil to a depth of 3\feet: Sand [] Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe Hardpan ❑ Previous Application Made: Yes ❑ N09 New Construction: YesK 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----------------------- Disposal Field: Distance from nearest well___________ ___Distance from foundation--------------------Distance to nearest lot line__-__--.____--___ ❑ Number of lines-----------------------------------Length of each line----------------- Width of trench Type or filter material______------------------Depth of filter material----------------------_Total length-____-_-____-___._____. -----------------•- Seepage Pit: Distance to nearest well ___------------------Distance from foundation------------------- Distance to nearest. lot line----------------- _ _ _______________ __ __Lining material-------------------- Diameter-----------------------Depth----- ❑ Number of pits . Cesspool: Distance from nearest I w-e-ll_ -- Distance from--�f�o-u--n--dation___- ......__.Lining material-- � �-1__ Rf Size: Diameter--------- -------------- ---Depth--- --- - -- ------- ------_--_ ----Liquid Capacity----:--- ----gals. , . rivy: Distance from nearest well-------------------------------------------------Distance from nearesf bu;Hing ❑ Distance to nearest 1 -=------------------------------ lot'line --------------------------------------------------- --------- Remodeling and/or re airing (describ ):____ _ - ------------- ----------- ----- -------f----- j 'F ---- . T-� -- - -- -------------- ------ - --- ------- -- - ----- - .--- --------------- -------•------------------------- ----•-------------------------------------------------- I hereby ertify that I have prepq d this applicati and that the work will be done in accordance with San ordinances, State laws, and rules and regulations of th San Joaquin Local Health District. }Joaquin County (Signed)--------- - - �' "' "L = (Owner;afid/or Contractor) By: --------------------------- ---------------------- ----------------------------- --------- Title (Plot plan,.showing size of lot, location of system in relation to wells, buildings, etc., can be placed on revere side FOR DEPARTMENT USE ONLY APPLICATION ACCEPTEDBY_ ,F___-_._ - - - DATE_ _____.-____-_-_._ - ----------------------------------- _ REVIEWED BY ------ - - ----------------------------------------------------------------------- ------- DATE.--- BUILDINGPERMIT ISSUED---------------------------------------------------------------------------------------------------- DATE------ ;; --------------------------------- -------------- Alterations and/or recom ndations:_.__ -------------- t -----------------------------•---------- 3= 6` ------------------------------------- (� 'INAL INSPECTION BY:----- �. Date_._ f SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Street 814 North "C" Street r:} Stockton, California Lodi, California Manteca, California Tracy, California ES-9-2M i0-52 Revised W-2100