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APPLICATION FOR SANITATION'_ �RMIT Permit No. Y---____ [Complete ------- (Complete in Duplicate) Date Issued ---- --- ll Appli n is hereby made to the San Joaquin Locai Health District for a permit to construct and-a install the work herein described. This'�a'pplication is made in compliance with County Ordinance No. 549. ki (2"Q f4 0 ADDRESS' A L CATION--- �J; --------------- ------------------------------------------------_ Owner's Name-------------- ----------- ---------------------------------------- ------------------------------ ------- Phone Address---------------------- - - --- ----------- ----- ------ ---------------------------------------------- --------- "Contractor's Name--- ----- ----------------- - 7----j< ------------------------------------------------------------ Phone-A---- I Installation will serve: Residen ce [] Apartment House [] Commercial E] Trailer C' Motel E] Other �!�! Number of bedroom's Number of aths - Number of living units."�. h AV7'=& size ------ --------------- Water Supply: Public systemb Community system ❑ Private Depth to Water Table -------- ft. Character of soil to a depth of 3 feet:—Sand E] Gravel ❑ Sandy Loa-rn 0 Clay Loam [] Clay E] Adobe Hardpan [] 00' Previous Application Made: Yes T"o No El New Construction:--Yes ❑ -No E] FHA/VA: Yes ❑ No TYPE'OF INSTALLATION-AND-SPEC I FIC-ATIONS,:- T ,N septic tank or'cess'ool perrhiffed if P'Uilallic sewer is available within 200 feet.) 0 p LicT at aZ Distancenearest well------------------------Distance from found ion------------------- ----------------------------------------------- No. of cor�parfmenfs--------- -------�__Si7e_- ------------ :------------Liq' u�d dep�h--------------------------Capacity---------r-------------- PoSa �irelcl: Distance from -----Distance from foundation----la--------Disfance to nearest [of line---Z_ tell I Number of lines------ Length of each line----/00--- ----------Width of trench-----2_41��,/---- ---- th Jf-filfer' mat',ial--- Total lengf Type of filter mate p 0 e h------2_0D_--------------------- s. Seepage Pit: Distance to nearest well____ fd-undaf Distance to"nearest lot fine----------------- El Number of pits..................%----Lining material----------------r......Size: Diameter--------------------- Depth---------- _-------_-----------. Cesspool: epth--------------------------------- Cesspool: Distance from nearest well-----------------Distance from foundation-------------1......Lining material------------------------------------- - El Size: Diameter---- ------ i 1� v -------------------------- ---Depth----------------------------------------------------Liquid Capacity----------------------------9'als. "I r,1, ,, ,.., _,. -I- - _T_ :. - _� t I - � . ': -.- i �_ ,=rte. = .- Y= Distance from n �res+ we]-------------------------------------------------Distance' from-nearesf building--------------------------------- Distance-to,nearest lot-line------_----------- ------- ----------------------- ------------------------------------------------ -------------------- Remodeling and/or repairing (descri,be):--- --------- ------------------------------------------- ------------ -------------------- = ----•--------•----•----- ---•---------------• ------------------------------------- --------------------------------------------------------------------------------------- --------------------------------------------------- ---------------------------------------- -----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------I------- ----------------------------------------------------------------------I------------------------------------------------------------------------------------------------ ------------------------------------------------- c I hereby V�that I have prepared this application and that the work will be done in accordance with Son Joaquin County ordinances, Sta a [a s,la s, and re I tions of the San Joaquin Local Health District. (Signed)------------j 4--------------------- --- - ---------7------------------------------------------------ ----- ---------------------------- 2mv** Contractor) Y•---•------------------------------------------ - -- ------------(Title)--- ---------------------:------------ --------------------------------------------- ------------- (Plot plan, showing size of lot, location of system in relation to wells, ildings, C., can 6e placed on reverse side)' FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY_Z.___*----------------------------------------------------------------------------------- DATEY --------------- ------------------------------------- REVIEWED BY-------------=- -------- ----------------------------------------------------- --------------------------------- DATE--- PERMIT ISSUED----- ----------------------------------------------------------------•----------•--------------------------., -DATE--------- ---------- Alterations and/or i-66orn!qpjidations:------- - --------------------------------------------------------------- -------I-------------------- ...... ------------------ ------ --------------------------- -------------------------------------------------------------------------------------------------------------------------------------- --------------1----------------I----------------- --------------------- ------------------------------------------------------- -------:--------- ------------------------------------------------------------- A ----------------------------------------------------------------- ---------------------------------------- ------------------------------------------------------------------------------------------------- 4 ---------------- ----------------------------------------------------1!-------------------- ---- -------- ---------- ------ ----------------------------------------- -- -- --------------------------------------------------------- BY:---- --- -- ------7- ------- ------------- - FINAL INSPECTION ------------- ---- -- -------------------------------------- Date........ ------------------ -------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 7 130 South American Street 300 Wes\fOak Street 132 Sycamore Street 914 North "C" Street Stockton', California Lodi, California Manteca, California Tracy, California Revised 1.57 FY.00.