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AP,.. _CATION FOR SANITATION PERM,,;, Permit No. 4 l (Complete in Duplicate) Date Issued . _ � Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the o e i rE ed. This application is made in compliance with County Ordinance No. 549. JOB ADDRESS AND LOCATION T : a � -- --------------- OwnersName------------------ ------- - ---------- Phone------------------------------------ Address---------------- --------------------Address----------------.............----------_--- -------------•••---------------------------------------- ....... ------ -------------------l -._..----.------------••------------ Contractor's Name------ _ :_._..: .....T.-----/ x-------- � v-�----- ---� ---- --•-- Plhone--_.-_--_---------------------- Installation will serve: Residence ❑ Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other a �dorJG Number of living units: ________ Number of bedrooms ________ Number of baths ........ Lot size ------..._.__.__----________________________________________ Water Supply: Public system ❑ Community-system ❑ Private K Depth to Water Table ________ ft. Character of soil to a depth of 3 feet:. Sand ❑ Gravel ❑ Sandy Loam Q Clay Loam 1' Clay ❑ Adobe Hardpan ❑ Previous Application Made: Yes P No ❑ New Construction: Yes kj No ❑ Awtt,0 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...1.00_._____Distance from foundation__ 1 5_______-Material_____ ____ _ _ -- --=---- -- ------- No. of compartments----------�'-•-•__--._Size----7X__�--�-.X2.�.IoLiquid depth------�'-{f-��--------Cepa itY--Q'-4"p-p---• Number of lines_______7____ ____: p 1 0�......Distance from foundation----I[�----------Distance to nearest lot line................ r ;.._-.- ------Length of each line-------_-I 0.0-- .- ...Width of trench---------�-_ k_______"_____--- Qis osal field: Distance from nearest well:_ Type or filter material_ ___ ► �__---Depth of filter material-_-----I:g�__------Total length..............�OO--------------____-- - Seepage Pit: . Distance to nearest well----------------------Distance from foundation....................Distance to nearest lot line------ ❑ Number of pits------------------ ---Lining material-----------------------Size: Diameter-------- --------------Depth---------------------------------- Cesspool: Distance from nearest well.----------------Distance from foundation--------------------Lining material________-_-__-_---_-____.__________- Size: Diameter-------------- ---------------------Depth-----••--------- -.-------------------------------Liquid Capacity--------------------------gals. I Privy:. Distance from nearest well--------------------------------------------------Distance from nearest building.:-_-_-__-._-----______________.____._._. ❑ Distance to nearest lot line--------- -------------•------------------- -----•---------------------- t Remodeling and/or repairing (describe):--------- �'° ------•--------.--------- ---------=------- � - -------- --- ---------------- --- -•- • ------ ---- ----- --- - -- --- --- --- ---I---------------------------------------------------------------------- ------------ M t`hereby certify that l have prepared this application and that the work will,6e done in accordance with'San Joaquin County ordinances, 'State laws, and rules and regulations of the San Joaquin Local Health District. (sign ..... •--------------------------------- -------------------------- Owner and/or Contractor By:-------------------------------------- .........____-------------------------------------------------------------------------(Title)--------------------------------------------------------- ------ (Plot plan, showing size of lot, location of system in relation to wells, 6uildin..S, etc., can be placed on:.reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY------------ -----------•----------------------- DATE----------- --------------- •-------------------------------- ----- HATE----------------f-Z=�-- - - REVIEWED BY ------------------------------------------------------------ -. --------------------------- V--------- PERMITISSUED---------------•------•-•--------------------_----------------------------------------------------- DATE...............:------------ Alterations and/or recommendation --- -- ---- -------- - .--••-----•--- - - - ---Q h Y1 l �j------ G-----7-� - -- _.r3----•--. c� -• .2 -- _' .1..--- J..-------- j ------------ -- _____ .. __.___.___ __ __ __ _____r__.__.r..____._.___ .._______ r // t FINAL f SPECTI BY%- ----------- ----- -- --- ----- --- ---------------- SAN --------------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 ES-9-2M 10-52 Revised W-2100