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�F �rG�+a�"�rl+�,�..r. �� ..b'�ii_.aec./L✓ �"' �„ R=/ Y a / _ d hr��+ F 6 �,,.�APPLICATION FOR SANITATION PERMIT Permit No. _."��__ 9 .c%4� aw (Complete in Duplicate) / Date Issued Applica-lion is hereby made to'the San Joaquin Local Health District for a permit to construct and install the work herein This application is made in compliance with County Ordinance No. 549. described. JOB ADDRESS AAN�D L CATION_ 51(577/999/fJ ■I -"" ---"" -"V.fl-._-_ F �,'�/J-f- ." _""-"" I a Owner's Name_"__"" ' Address -------------------------- -- Phone--,/4f _c�[ c - a?l --- �---------------------------------------------- Contractor's -------------- ame-------- =• -�,�ne�.- ----•------------------------- -------------------------------------I--- _________ Installation will serve: Residence Apartment House ❑ Commercial Phone'"" ------_-----"------------- / ❑ Trailer Court ❑ Mofel.0 Other ❑ Number of living units: /--- Number of bedrooms __""- Number of baths � -- /----- Lot size ---Water Supply: Public system Community system ❑ Private E] Depth toWater Tablec�,"-Q. f-"-�� . / i Character of soil to a depth of`3 feet: Sand [] Grave! ❑ Sandy Loam ❑ Clay Loam [] Clay El Adobean Hard Previous Application Made: Yes ❑ No El 'New Construction: Yes El No ❑ K p ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: Y (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tank: Distance from nearest well�__-`�'�_.Distanc� from,foundati n--")"_""____.Material--_ No, of corrpartmetits" ,+;.,, �j �� ` - d-- -----------Size_-' A-•-d,""Liquid depth--- Disposal Field: Distance from nearest well.,_.;- -~_Distance from foundation"_.. Capacity."" .2»�_---._.Distance to nearest lot line_" Number of lines"-"-__."_" _ " �- -- ' 'Length of each line-------------- it Type of filter material---- //�/J"/� Depth of filter material-_:" width trench_ �/_ _ �� • ,�-�-- Total length--- ------ Seepage Pit: Distance to neare"sf well _____-_--Distance from foundation:_"""-___""_ \ ,1' __-_---.Distance to nearest lot line_-._"_"" """__._ ❑ Number of pits-----------------" Lining `material------"""_-- - --------Size: Diameter----------------------Depth----------------It Distance frorrr nearest well""-_"__._"-_"-`_ Distance from foundation"__."- -"-_-' ----.Lining material_ ❑ Size: Diameter-----------------------'-- ----------------- --------Depth------ ------ ----=-- - -- ----;--- Liquid Capacity----------------------------gals, Privy: � Distance from nearest well.- ,-"_____________ ❑ Distance to-nearest,lot line------ --------- ---=- ._."Distance from nearest buildin- g--------------------------------------I.- -------------------- -- Remodeling and/or repairing (describe)-------------------------------------------------- - --------------I-----------------------------I-----------------------------I—--------------------------------------------------------------------------------------------------- -------------------I--------------------------------------- ------------------- ----------------------------- ---------------_:------------- --------- --- -..------------------------- -- ----------------------"__"""-"""""__""-""" ".""".__-- "_"""""-_"_""i_•--•-----------------•-----_-----_-------__---_-__---------------__---_--__-_-_--------------•----------- -----"r---------- 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 rubs and regulations of the San Joaquin Local Health District. Si ned 1 [ 9 - w.. --------------------'---------- r� r --- -------------(Owner and/or Contractor) --------------------------------- -- -- - - --------- -- ------ --- --------------•------------------------ - - Title) =`y [Plot plan, s owing size of ot,. ocaiion of s+em in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY-_-"_""-.-"_,-------_ r ` 1 REVIEWED BY---------------- -- --- DATE - ------= BUILDING PERMIT ISSUED---•.--------_-----____ DATE_."" -----_ l ---- .------------------- -------------- DATE------ ------------------- Alterations and/or recommendations:_"""_"- .-__." . -------- --"--------------------•-----------------------------------------•--------•----•----------••-------•--•---------------------- f -- ------ ti a := : - ......................... -f. - 3` ----- ------------- r ' �- 3 � '. - - - - :::�--- -------------- FINAL INSPECTION BY:. � t�� s —� g o e9K Ar/7 Date rG " " -----^--- N JOAQUIN LOCAL HEALTH DIST !CT 130 South American Street 300 Wes} Oak Scree} 132 Sycamore Street 814 North "C" Street Stockton, California Lodi, California Manteca, California Traey, California I ES-9-2M Revised W-2100 r