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APPLICATION FOR SANITATION FERMI ee' rrn4 No_ ____ _________ ___ (Complete in Duplicate) Date issued ----��/�... Applicaa-ion 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. 549. f. JOB ADDRESS ANP/LOCATION - {� 4`va �'�' ---- Owner's Namet ------- '� Phone Address............... �'�` _.... _ '----------- --------------- Contractor's Name------------------ • --- ------ -----------------------------------------------------•------ -----------•------------------•------------ Phone------------------------------------ Installation will serve: 'Residence Apartment House E] Commercial ElTrailer Court ❑ Mote{[IOther ❑ Number of living units: ----)---- Number of bedrooms ..../-. Number of baths _/_____ Lot size go I Lfc Water Supply: Public systemttconmunity system ❑, Private ElDepth to Water Table ________ ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ AdobeHardpan ❑ Previous Application Made: Yes ❑ No e New Construction: Yes%No ❑ 1 TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank-or cesspool permitted if public sewer is available within 200 feet.) f Septic Tank: Distance from ne est well Distanc from foundation____/_D_�_____.Material_____ 1! :2�Z� No. of cc' pa�tments.____ q p f -- ----------Size--- X mid de th------ _J--------------Capacity----: - -r------- Dis osal Field: Distance from nearest well---Up_ _Disfance from foundation---p a � - ----.__.-.Distance to nearest lot line_ _ Number of lines_________d7,t.Jk.:,-----------Length of each line___.____�_Q_f--_____.Width of trench _�-_�_--3-�-_------ Type of filter material-------------------------Depth of filter material-------------------_----Total length_____ ---Q___________________._-__-- Seepage Pit: DistancWfo 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 -:--_- 1. —�pe th____.____•--_ --_=__ _ ._Li uid4Ca aei.t - els. �> Privy: Distance from nearest well----___.__:______________________________________Distance from nearest building----------._- _ __-----_____ _____________. }. 1 ❑ Distance to nearest lot line_--------------------- ---- ----=----'--------------------------------- "---------------------- -- - --------------------- - - -- --- ----------- ---•--------------a------------------------------------F----•-:_*•---•----------------•--- ------------------ -----------------------•-------------••------------------------ Remo Remodeling and/or repairing (describe):-------------------------- ---------------------------- ,.._ ___________________________________________•.__-___-______''_-___.___.__.____________._______________-_____-________________-•____.._____.__________---___•_________-______________•-_-________A___.--_________.____________ S --- - -- --------—----------------- -------- ------- -p---------------------------------------------- •--.--------:------•-.-------------------------------------•-------,-------------------•-- +---- f I I herebycertif that I have re ared this application and that the work will be done in accordance with San Joaquin County i ordinances, S+ to laws, and r les and regulations oft San Joaquin Local Health District. "CA [Signed}_-- _ _ -. _.__. .......... I _ rt.� Yl�r! .- ---- ----L- ------------ (Owner and/or Contractors By:---------------_-----t ;:..... (Ti+le ------------------------------- - ------------- ---------------- (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc.; can be placed on reverse side). vr- _ FOR DEPARTMENT USE ONLY -k 49 APPLICATION ACCEPTED BY---- -----f- - ----------------------------------------------- -------- DATE------- REVIEWED BY ------------ --------------------------------------------•--------- ----------------- DATE__ .. BUILDING PERMIT ISSUED-------------- -- Z ---- --- ------------------------_------••---------------------- DATE------------ ------- --•-- '- Alterations and/or recommendations:__== `--- ----- ------ ------- -- ------- ----•-------------------------------------••-------------------- / _ _ _ - - _-------- .------------------------------------------------------------------- ----------------�------------------------------------- -`--------- --- - ---- ---------------------------------.------------- ------------------------------------------------------:---------------------------------------------------------------------------------------------------------- ---------------------------------------------------------- ----- ----------------------------------------------------------- l. FINAL INSPECTION BY:.-.._...._: s� cl--�--- ---��- ---��----�----------=--- [ Date--- - -- ---------- ---- --,--------------------- -�--------------• s � y SAN~JOAQUIN LOCAL HEALTH DISTRICT t 130 South American Street 300 West Oak Street 132 Sycamore Street 814 North "C" Street Stockton, California _ Lodi, California Manteca, California Tracy;.California " r �;� _ ES-4-2M__�Revised W-2100 I � �