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APPLICATION FOR SANITATION gg ATION PERMIT Permit No. � ' k (Complete in Duplicate) Date IssuedI3Ji2� App ication 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 Or inance 'o. 549. JOB ADDRESS ANDQCATION- -- -jx--------,,#_ Owner's Name------------ - - ---------)00 --- --- ---- Phone Address ---- -- _ �'y` ., ------ ---- --- - ---------- Contractor's Name-- ---•- - - - ---------� -- -�'---� -- - �.•��/ �` - --- Phone. Installation will serve: Residence ❑ Apartment House ❑ Commercial ❑ Trailer Couft ❑ Mo el ❑ Other Number of living units: __/__ N er of bedrooms -� ❑ 4 - Number of baths __-_-___ Lot size --_-__ __-:� r � ;:F Water Supply: Public system Community s stem ---_ ----------------------------- Y Y ❑ Private ❑ Depth to Water Ta#a - ft. Character of soil to a depth of 3 feet: Sand - Gravel❑ .Sandy Loam Clay Loam ❑ Clay ❑ Adobe' ardpan ❑ Previous Application Made: Yes ❑ No New Construction: Yes No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Ta Distance from nearest well _ __,_-Distance from foundation_/�_ Mater I - _ � + ❑ No, of compartments-___ Size-„.�_ �---__Liquid depth--_ -------- ----- Xl Dis osal Fie �� -------Capacity-_-��_-_--_ p Distance from near st w i -------.Distance from foundatio - 40 t-,- 0 �/ -- Distance to nearest lot line_- ❑ Number of lines__ -__ /_ --_ Len th of each line-__-_ _ g -� Width of trench- - T e of filter materia >� Yp ��- r--Depth of filter materlai___�_�__- -------Total length--------�0-------------- r�{ Seepage Pit: Distance to nearest well El from foundation-_---_-___-_-_---_. V' # Distance to nearest lot line-----------------. ❑ Number of pits----------------- ---Lining material-----------------------Size: Diameter_---------------------Depth--------------------------------- Cesspool: Distance from nearest well-----------------Distance from foundation-------------------- material__-___-__-_---._---______ - ❑ Size: Diameter- --- --- -- ----Depth------ -- -- Liquid*Capacity gals. Distance frorrt newest well --_____ _---_-,-_-Distance from nea`�"re fi buildi -� ----- g ----------------------------------- 1 Distance to nearest loft line--____-__----__-_-_ f -------- Remodeling ------------------- 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 and rules and regulations of the San Joaquin Loc 1 Health District. (Signed)----- . ------(Own and/. Contractor B ) Y• -- - ---------------------------------------------------- --- - -- ----------{Title):--��.•. ---------. (Plot,plan, showing sire of lot, location`of system in relation to wells, buildings, etc., can be placed on reverse side). W FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY--- --------------- ----------------------------------------------------------------- DATE--�' REVIEWED BY `----------------------------------------------------------------------------------- DATE_ BUILDING PERMIT ISSUED--------------- - _ DATE--- Alterations and/or recominendafions---------------------------- -- �” � ------------------- ------------------ -- --------------- FINAL INSPECTION BY:------- C-frDate- ------ SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Streef 1300 West Oak Street 132 Sycamore Street #. 814 North "C" Street Stockton, California f Lodi, California Manteca, California Tracy, California ES-9-2M 8-51 Revised W-2100 I