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l 7 r APPLICATION FOR SANITATION PERMIT Permit!'No. .._._ (Complete in Duplicate) 1-2 i Date Issued ��.. Application is hereby made to fibs San Joaquin Local Health District for a permit to construct and install the w��rk here' described. This applicafion is made in compliance with County Ordinance o. 549. '� ,, JOB ADDRESS AND LO �I�I Owner's Name---------•--------•--- }-----•�-�._-• . _ � - It Address_. .x,i-- r.._... hone 1 =. . I � �[ ----- - - Contractor's Name.._ �yI `` �'`'f� ------------- --- -----.---:__. .._.. Phone (d-- _. . Installation will serve: Residence A t hent House ❑ Commercial ❑ Trailer Court I' Number of living units: --/ ❑ Motet ❑ Other ❑ ' -- umber of bedrooms Number of baths'./.. Lot size .___-____ � _ Water Supply: Public system -Coinmunit s stani F _= Y Y ❑ Priv Depfh to Wafer•Table36 ft, �'7s_.c 1/D Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam Clay Loam ❑ Clay [] Adobe Hardpan ❑ Previous Application Made;' Yes ❑ No [] New Construction: Yes No 0 ' TYPE OF INSTALLATION 'AND SPECIFICATIONS: we (No septic tank or cesspool permitted if publics r is available within 200 feet.) Se tic x p� Distance from nearest well �-----Distance fro foundation_.-- --------- Material ,. No. of compartments__ �,� a ze-- ,"f t Dis oral d: _�/ z. Liquid depth-------- _- - p` Distance.from nearest ell// Distance from foundatio -- - ` -Capacity_._ ___ Numberlo{ lines___--- - --------Distance to nearest to I ne__.__,_.--- Len th of each line________© -:_- ` Type of filter material _- Width of trench:_--��I�-� - - 9 �'J �s E_Depth of filter material___f- ----------- Seepage Pit: Distance-to nearest well_._-___-"-__-_ Total length-- Seepage Distance from foundation _ _ _.Distance to nearesfillot line----------------- ----------------- a p g Size: Diameter - Depth Cesspool:0 . Distance' from nearest well-----------------Distance from foun Number o its u------Linin material Sr dation----------- 1 ❑ ti S+ze:-Diameter---------- ----------------- ---- Depth------ = -= = = . -Lii n material -1------- Lining t ;1 - <... ._ . quid Capacity== --_'`,,^::''-=-�pls. Privy: Distance':from nearest welt_____________________ 1771 Disfiance to nearest lot line____ ---------------------------Distance from nearest building- _ _-______-- �N 1 ribeJ: Remodeling and/or repairing fdesc �. �� ________________________________________________ ___ ___ _________________________ -- _ ---------•------•-------- ----------------------- • ---------------J;I ------ --•___------------a Y __ -----------------------------------________________________________________________ _•__-__...__-- ____________________________________________ _ _______ __ .. _______ _.____-__._ __._-___._____.. __.- ____.--____ { 1 hereby certify that I hive prepared this app licat__ ion and that the work will be done in accordance_.wifh_San�FJoaquin. Count_ ordinances, Sfat lawand rules and regulations of the San Joaquin Local qealth District. (Signed)---- r 4f Af i -----------' : By:---__ � i ( ner and/ r Contractor) ------------------------------------------------------= [Trtfe)-- -- .Ick I --- (Plot plan, showing size of lot,,location of system in relation to wells, buildings, etc., can if placed on reverse side}.. FOR DEPARTMENT-USE ONLY APPLICATION ACCEPTED BY._ S - REVIEWED BY DATE - : BUILDING PERMIT 1SSUE0. I�------ DA7E____ ,.i<- IM, s Alterations and/or recommendations:.__----.__.. DATE---- # -------------------------------------------------- ------------- ----------------- �� } ------ -- ---------------------------=!�' ---------- --------- l' --- .............................. l --- ------ - --- -- ----- ------ --------------- ------------ FINAL INSPECTION BY:-----��--_--_-- y�/ 2rl I D fe `r - - --------------- ;, 5AN JOA QUIN LOCAL HEALTH DISTRICT STRICT 130 South American Street 300 West Oak Street Stockton, California 132 Sycamore Street , 814 North "C� Street Lodi, California Manteca, California Tracy, Califrola ES-9-2M 10-52 Revised W-2100 l - 1