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APPLICATION FOR SANITATION PERMIT Permit No. �1 J� (Complete in`Duplicate) Z. l Date Issued Y Applica{ion is hereby made to the Sari 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. r 71/ JF F a JOB ADDRESS AND LOCATIO ----------- - -----0--------- ----- - ----- Phone----------------------------- ------- Owner's ame-------------•--------- --------•- -•----•-- Address-------•----------------- - = iPhone----------------------------------- Contractor's Name. -------•-- Installation will serve: Residence partment House ElCommercial E] Trailer Court ElMotel El Other / ------------------- Number of living units: .-1.---- Number of bedrooms ---2umber of baths _--L Lot size _--_---'�5--- Water Supply: Public system' Commumtyrsystem,.[]+Private-❑Depth i•o Water-Tble --------"ft: Character of soil to a depth of 3-feet: Sand rGravel ❑ . Sandy Loam E] ❑ .Clay ❑ Adobedp ❑ Previous Application Made: Yes o1❑. New Construction: Yes oQ LJ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) _Mater l (r �4 Se tic Tank: Distance from Weare} well._ -- -Distan a fro fou da ion-- ---------------- U� ✓ Capacity No. of compartments___.__.----Size--Y' -Liquid depth--._____ 4 ,,,,,// �Q_'_ Distance to nearest lot Iii e___ Disposal Field: Distance from nearest well__/747Mstance from foundation. _ ` 4 Number.of lines---- � g v `V �_-•- Len th of each lin�a(Q_�.3� ---r .Width of trench.-._____�__ . T e of filter material- .lx_ -:_ Depth of filter material_____�_ _l__--- --Total length._____ _ ___________. YP nearest well " "� "�Distance'from'foundari______________,___:.Distance to nearest lot line--------- Seepage Pit: Distance to Number of pits---- '--------------Lining material--------------- ` ..Size: Diameter---------------- Dep+h 1. l Cess ool: Distance from nearest well-----------------Distance from foundation--------------------Lining material-_--_-_-.---_------.-_-----_-_.----- p Size: Diameter-------- --------- QePth -----------------------------.--- Liquid Capacity----------------------------gals. qu r ❑ Distance from nearest well------------------------------------- ---- Distance from nearest building------------------------------------------ Privy:. --- Distance to-nearest lot line:-----------------------------------�---'•=------ -----------�•-------- =- -----------------------•-------- =--•-------=== ------ Remodeling and/or repairing (describe)---------------------- ------- ---------------- '. --------- ------------------•-------------------------------•----- y ________________________________________________________________ - _--__,9 y-----_-.-_-_---..___._--__----------__.-___.---_.--_-_-_---._---------.-__-----_---_---- 1 _ ---------------------- -------------------------------------------------------------------------------------------------- __________________________________-------------------- _________________________________________________________________ � ......_ __ _____ ___________ _______ _- ___ ------------_-----------_______---_______------___------_-.___--------_.------__-------._-_----___----.------.---__-__-_----_-___.__._____- l:hereby' certify=that-I have prepared this.application and-Aha+.the,work will be done in accordance with San Joaquin Cou _ ordinances, laws- and rules and regulations of +he San Joaquin Local Health District. r ---_-------(Owner and/or Contractor (Signed �''� Yi'r ---------- -------- (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). ( i FOR DEPARTMENT USE ONLY % - DATE-----/ ---- APPLICATIONACCEPTED.BY ------------- -------- ------- ------ ---------------------------------------------- REVIEWED BY`------------------------------------------------ - ------------ ---------- -- ----------------------------- ------ DATE--- -------------------------------------------------------- BUILDINGPERMIT ISSUED------------------------------------------------------------------------- --------------------------- DATE ' Alterations and/or.recommendations:--- ---------- ----------------------------- -------------------------•------- ---------------•--•----••----•------------------------- . ------------------------------------------------------------•-•-------- ----•- ----------------------------- ----- { -. __________________________________________________________________________________ 11 . - ------------------ _ Q ..--------------------------- _-------------------------------------------------- _______________ --- ------------------------ --------- FINAL•INSPECTION BY:-_-____-___i-------- - -- ate------ --------------------------------------------- •----------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 30D West Oak Street 132 Sycamore Street 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California ES-9-2M ; Revised W-2100 - .