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rUK urri(�EPsE: + -------------------______------------------__----------- APPLICATION FOR SANITATION PERMIT Permit No. ..1....r��!_..1. ----------------------------------------------------- (Complete in Duplicate) / ---------------------------------------------•-.---..--- This Permit Expires 1 Year From Date Issued Date Issued 2/............... Application 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 49. �'. JOB ADDRESS AND LOCATION__._ - ci'-- ------- --------I__ 1, _.. = Owner's Name.. �f Ate`-- x..h_�6Y) I�{i ------- (.& ! ------ Phone....---- ---------- Address.------- -- - - - • -- Contractor's Name 13.. : ! f -•-- ------ •-- ----�------------------------ Phone = Installation will serve: Residence 9 partment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: .J.__.'Number of bedrooms %3-- Number of aths /�i Lot size �............................ Water Supply: Public system m Community system ❑ Private epth to Water Table elft. Character of soil to a depth of 3 feet: Send ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe`M_<ardpan ❑ s Previous Application Mede: (If yes,date------- ------------) No New Construction: Yes, ❑ FHA/VA: Yes ❑ No 2---' TYPE OF INSTALLATION AND SPECIFICATIONS: i (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic mak: Distance from nearest well___.�V_________ Distance from foundation___/A_�._.__._.Ma rial�0_�Q�"l. -�,!'................ �- . No. of compartments--------- ________._Size__ / __ ____.___Liquid depth_.--__ -___Capacity___Ov_________ Dis osal d: Distance from nearest well_t5-P___�..-_Distance from foundation-. ._- f p �} �j ��........Distance to nearest lot I;ne____ _________ Number of lines-------2-___�_-J-___________Length of each -------------Width -of trench__z_Y--�................... Type of filter material----R'2.-_.±r'CKkbepth of filter material_)�__r-----------Total length......i _ e ••_--. SV•.................__.__.._. Seepage P. Distance r to nrest : ` -.Distance from Distance to nearest Iqt line.J.__.__ Number of pits _- - L n Sze: D, etera ------.Depth---pi - ----•••-------• V Cesspool: Distance from nearest well_________________Distance from foundation------: ------------Lining material______..____._______________.__...... ❑ Size: Diameter------------------------------- -------Depth_------------------------------------------------Liquid Capacity- ........ ----....gals. Privy: Distance from•nearest well-------------------------------------------------Distance from nearest building__________-_________------_-____-__--__-.. [I Distance to nearest lot line--------- --y-----------------------------------------------•-•-----------------------•------- Remodeling and/or repairing (describe):------------------- ------ ---- -----•--------' ................... ordinances, State laws, and rules and regulations of the San Joaquin Local He I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County i ,,fes - --•----------alth Qis#rict. (Signed)................•_-,/ -1 ----en d_ _..__ (Owner and/or Contractor) By:..................................... r ---•----•--•---_-.Title - (Plot pian, showing size of to , of system in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY---- "------- ----------------------------------- DATE------ ------ REVIEWED --REVIEWED BY------------------------------------------- - -------- ------------------------------------------------------ DATE---------------_------------------------------------------ BUILDING PERMIT ISSUED--------- ---------------------------------------------------------- DATE------------------ •-----------_--__-_____---- •-•------... A rations and/or recomend'qtions:__-----__-•-- --_-•_-- - , - ---------- ----- -------------------------------------------- ------------------------------•-----•------------ ----- ----------------------------------- •---------------- ; FINAL INSPECTION BY:._r _._ .. - _._ Dete._.___ _`-_ � -� �— s SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Strut 300 West Oak$"of 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,California Manteca,California Tracy,California ES 9 REVISED 8-09 YM 0-61 ATLAS