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r ` Q 70 0 moi`/ APPLICATION FOR SANITATION PERM7e Permit No. (Complete in Duplicate) Date Issued __�_7_. 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 OrdiQpjae No. 549. WJOB ADDRESS A C O l�J. - -- - Owner's Name-�------ I -!_._ I-- --------- ------- --------------- --- ----------- ---------------------------------------------- Phone_ -_/ ! 49--------- Address ! "`- ..-•-.- W Contractor's Name-- ---• ---- •-------• ---------•-------- -------------•----------------------------•--------------•---------------------------- Phone----•-------------------•---------- r Installation will serve: Residence Apartment Mouse ❑ Commercial ❑ Trailer Court ❑ Mot?l ❑ Of4-1 er ❑ J o5dl Number of living .units: -_-1---I umber of bedrooms _-Z__ Number of baths ---I_-_ Lot size -------------- --- - - -_ ---_--_._---.-----___---_ Water Supply: Public system .'Community system ❑ Private ❑ Depth to Water Table -------- ft. Character of soil to a depth of 3 feet: Sand Gravel ❑ Sandy Lo;PN/o Clay Loam F] Clay E] Adobe Hardpan C]Previous Application Made: Yes E] No New Construction: Yes ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: r (No septic tank or cesspool permitted ik public er is available within 200 feet. --------Distance from fou ~ation- - - ----------Materi -_ _____--------------------_--- _.---.-.--_--. Septic nk: Distance from nearest well---- V-- e-sa3.Xo_X- --Liquid r�epth -----'T : Capacity 1� NO.! No.�of compartments____________ _ ___ iii Dispos Field: Distance from nearest well- istance from founds#ion-'f/.- ---.___-_. istance to nearest lot li eel ._--.__: 21_______ _Length of each line_- Width of trench------- - --------------- --- Number of lines----_---_ _'_ /[' I Type of filter mater Depth of filter material----____1. - Total length_----.-._.!_o�r ____-------------- t 1 _ , Seepage Pit: Distance to nearest well----------------------Distance from foundation_-_-____---__-_---.Distance to nearest lot line---------------- _7 Number of pits------ ---------------Lining material-------------- Size: Diameter-----------------------Depth--------------------------------- Cesspool: Distance from well----------------- from foundation---.--__-------___.Lining material----_.--.---___---------------.--- -. A Depth-____------ .----_Li Liquid Capacity gals, ❑ Size: Diameter------------ - ------------- -- -------------- - - q P Y--------=-------------------9 Privy: Distance from.nearest well--..-------.-------------------------------------Distance from nearer# building------..----____-_-----_-----..--------- ❑ Distance to nearest lot line--------------------------'------------------------:------------- ;{--------------------------------------------•---------------------- '1 � Remodeling and/or repairing (describe)-------------------------------; .----•----------------•-•--------------------------- ----------------- -------------------------------------------------------------------------------- ----------•--------------------- ----------------------- r 4 I hereby certify that'l haveprepared this application and that the wo4will.6e done.in accordance with San Joaquin County ordinances, State laws, and rules and regulations.of the San Joaquin-Local Health District. (Signed)------- � �e-�-- -------------------- ------------------------- -- -------------------------------------(Owner and/or Contractor) - Sy:-------------=----------------------------•---------------------------------------------------=:;--------------------------------(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 APPLICATION ACCEPTEDB ---------------------------------------------------------------------------- DAT -�----------------_--------- -'--- =====_= REVIEWED BY----------------------------- - DATE--- BUILDINGPERMIT ISSUED---------------------------------------------------------------------------------------------------- - DATE------V Alterationsand/or recomm�ndations------------- ----------- ------------- ----------------- --------------------------------------------------------------•--------------------------------------- .............. ----------- ------------------------ ------------------------------------ --------- --- - --------------------•-- ------••-------------•------•-------••- ••------------------------------.--- %,\, --------------------• -----•--••---•--- ---------- = ----------------------- -------------------------- ------ ---- ----------------------- --------------------------------------- - -- ----------------------- ----------------- ----- -----------•-------------------------- ------I--------- -- ------Date------------ 1 ----91�� FINAL INSPECTION BY-------------------ll--- v .--�----- --------- 'f� 1 SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street i 300 West Oak Street 132 Sycamore Street 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California ES-9-2M 10-52 Revised W-2100