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{'j �C ----- APPLICATION FOR SANITATIO PPR IT Permit No_ ____ ._._-_ 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 work herein described. This application is made in compliance with County Ordinance No.. 5549. x( JOB ADDRESS AND LOCATION �Z-3` � ------ �"�� `"..� ��."�1�i-k'.J- �—�-- Phone___ _- cz0----•---- Owners Name--------------------------------------- -----�- - --Q ,AF�t - Q - ------------------- Contractor's Name-----------------------------e-21- ------a'` Phone -/-= 746 4Z - Installation will serve: Residence ® Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: __,____ Number of bedrooms __ Number of baths _1___ Lot sizeQ_--------------- Water Supply: Public system AdCommunity system fl Private ❑ Depth to Water Table -------- ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobeo< Hardpan ❑ Previous Application Made: Yes ❑ Nox New Construction: Yes ❑ No ❑ 4111..afo,--«17 TYPE OF INSTALLATION AND SPECIFICATIONS: [Na septic tank or cesspool permitted if public sewer is available within 200 feet. eptic Tank: Distance from nearest well__ "r __Distance from � _ _ - foundation____ �------.Material- --------- No. - -- --- ----,-----s'-- --- -- No. of com artments_____)--______________Size!Z�-�J-V_21 -Liquid depth------------------------- daci � --- - Disposal Field: Distance from nearest well__l"'t CkA ---Distance from found _/°ation_ a_�______-Distance to nearast lot line-------1_ �r 70--------------Width of trench-----. `.-------- Number of lines----------I_______i__��- Length of each line___` p Type of filter material--�__13r-Al C___Depth of filter material_---_92--'____-__Total length___--e1�_ ___________________ V 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. CA Privy: Distance from nearest well-------------------------------------------------Distance from nearest building____-____.-_____-__.-_.-_____________--. ❑ Distance to nearest lot line--------------------------- ----------------------------------------------------------------------------------------------------------------- Remodeling and/or repaii'sng (describe):___ -_ ____ �•`-------- `/ _ __ _________________________ ____________________________ ,3� Cd r _ `o. -• :------- ...l"`P __ .w.. '=" ' 'tom ---------f - 4r�...."' `4 _ ------=-------------------------------•---------•---------- f I hereby certify that I hayeAprepared this application and that the work will be done in accordance with San Joaquin Coun ordinances, State laws, and rules a d regul tions of the San Joaquig Local Health District. (Signed - ----t - --- - - ---- -- --- � _ {mer. . Contractor) �. l3 :. 3 ---------- ---------------------------------------------------(Title} 1- [Plot plan, shot mg size of lot, location of ysfem in relation to wells, buildings, etc., can be placed on reverse side]. FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY--- t -fp �- DATE------ --------- REVIEWEDBY-------------------------------- --- -------------------------------------------------------------------------------- DATE------------------------------------------------------------ BUILDINGPERMIT ISSUED---------------------------------=------------------------------------------------------------------- DATE------------------------------------------------------------- Alterationsand/or recommendations--------------------------------------------------------------------------------------------------------------------------------------------------- ------------ --------------------------- ---------------------------- ------------------------------------------------------------------- --- ______________________________________________________________________________________________________�--.___________-__________--------_________-._________________-----____________________i________-_____________________- FINAL INSPECTION BY--- ------------ ------------------------------------------------------------------------------------------------------------ Date l �' 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 '-racy, California ES-9-2M 8-5i Revised W-21o6