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_� / 7 APPLICATION FOR SANITATION PERMIT Permit No. ___________ ��. (Complete in Duplicate) Date Issued -�� - 4 %t � 06 Z—22-Y E "� V 14'4rA-� Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described. This a lip cation is made in compliance with County Ordinance No. 549. a AN � '� -----------------►- ------`---- e'-__t-_-_'-• '---------- -- - ----r!_ P o ---" -JOBADDRESS 1 . 3 Owner's Name_ ------- -------------- -- ------------------------ Contractor's Name------------ -------------------------------------------- Phone----------------------------------- Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ ggp ------------------------------ Water ---------------------- - Number of Living units: _�_____ Number of bedrooms ---f- Number of baths ---1--- Lot sizeLO___f_t___�"______ - --- I Water Supply: Public system ❑ Community system '❑ Private jM Depth to Water Table ">-ft. Character of soil to a depth of 3 feet: Sand Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe❑ Hardpan ❑ Previous Application Made: Yes M, No .Q , New -3 Constrction: Yes E] No 1Z TYPE OF INSTALLATION AND SPE1�FI (No septic tank or cesspool permitted if p lic� er is available within 200 feet.} Septic Tank i Distance from nearest vrell_____ ___ _____Distance fro oundation__--_�_'_4_-Material___" _ ______-��" -- - -- -------- -------------- q +� Ca acit ---- �o. �com5ea eQts Size -l- x r4 -)OLiquid d pt '30 p y-------- 'stance rom foun anon_____ ____ _ 'stance to nearestAt lin��_ _____.__ Disposal >=geld: Distance F"oe t we __ _. r7 p� Length of each line___ -f`-___Width of trench____ �/_____________=____J r Number of lines ----- ��------- Type of filter material--$7 Cr,r Depth of filter material------ length_______6--L!.1------------------------ N Seepage Pit: Distance to nearest well______________ _______Distance from foundation--------------------Distance to nearest lot line-------------- _� .ri ❑ Number of pits----------------------Lining material-----------------------Size: Diameter------------------------Depth------------------------------- Cesspool: Distance from nearest well-----------------Distance from foundation------------------- Lining material_______________________ ❑ Size: Diameter------------- =-------------------Depth-==-------------------------------------------------L;q!!id Capacity-�-;;--;;:-----------------.-gals Privy: Distance from nearest well---------------------------------------------_---Distance from nearest building------------------P k Distance to near st lot ine �: s.lJ `� _ -- ------ - - t �. ---- -------- -- Remodeling and/,or repai 'ng �escribe]: -- --------------- �_ r� �_- ----------- i t P A --- -__.... fir/.J L �--- - _ __ __ •_ i (�3sSi '� __-/YeL�Ry'i...f?.r- .--- -- ------- - --- ---�---------- -t q� �? -- ------------------------------------------------------------ I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State laws, and rules and regulations of the San Joaquin Local Health District. fi (Signed) ------ ---------------- -------------------------------------------(Owner and/or Contractor) i Title ---------------------------------------------------------------- (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT'USE ONLY DATE------ ---- ".�rJ� ------------------- APPLICATION ACCEPTED BY------------- - ------------- --------------- • �� ----_ .�------------------ BY-----------------------------_--------------------------------- 1 DATE------)- --------------------------------------------- REVIEWED BUILDING PERMIT ISSUED----------------- --- DATE-------------------------------------------------------------- ---- Alterations and/or recommendations- -- ^� !l a -----------------------------4�------------------- ------------"------------ ---------------- --------------------------------------------------------------------------''� ----------------------------- - ° -- ------------------------------ ----------------------------------------------------- ------------------------------------ FINAL INSPECTION BY:------ ------ --------- Date Date-------f �'�. ----------------------------------•---- __�-:---"--�----=------ - --------- - 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 Tracy, California ES---9-2M B-51 Revised W-2100