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PPLICATION FOR SANITATION ['�%IT Permit No. <br />-------------- <br />(Complete in Duplicate) <br />,,,e / <br />Date Issued <br />San Joaquin Local Health District - ora permit to conyuct a - <br />A 4.1 f Ze� <br />Application is hereby made to the S insfall the work herein described. <br />This <br />arplication is made in ompljan�� <br />JOB?/ County Ordinance No. 549. <br />A DP <br />ESS ANDCATION____`_��_� <br />- - -- ------------------------ --------- ------- <br />• <br />Owner's Nam ----------- ---- --- <br />---------- -- ---- - ---------------------- -------------------------------------------- <br />------ Phone ------------------------ <br />Address---- <br />--------------------------- ------------------- -------------------------------- <br />Contractor's Name-----------------------•--- --------------- -_Phone: ------------ --------- <br />Installation will serve: Residence E�]Appa ment House ❑ Commercial E] Trailer Court E] Motel E] Other <br />Number of living units: ___.---- Number of be I ., 31a <br />Tb roof baths -------- Lot size ----- -- ---- a <br />0 M ...... <br />--- -------------- <br />Water Supply: Public system El Community system Private ept to Water Table .7zff. <br />system ��rll 'pt f <br />Character of soil to a depth of 3 feet: Sand I-] GraveIX Sandy Loam El Clay Loam El Clay 11 Adobe E] Hardpan C] <br />Previous Application Made: Yes E] No Rr New Construction: Yes No ❑ PHA/VA: Yes ❑ No <br />TYPE OF INSTALLATION AND SPECIFICATIONS: <br />(No septic tank or' cesspool per -miffed if public sewer is available within 200 feet.) <br />c anwell_________from To ] —nd i , I_____ --__k4 <br />Septic T�k_­_—'DTs'far�c_efrom nearest e foundation____v__--_..M ------------ T, V <br />No, of comparfm 'nts-- )(10-A-5 ---- Liquid depth _.__"?/_____ ------------- <br />- - ---- -- Ca pacify -j- 3 06 <br />--------- 4 <br />Disposal Field: Distance from nearest well_.. Distance from founclation��__ ---------- Distance to nearest lot <br />Number of lines___}_______Len .of each linel-ml!%�--- --_Width of trench__'------------------- <br />C-& Depth of filter mate r�al <br />Type of filter material - -i--- - <br />* -Total length__---_--- ------------ <br />F <br />Seepage Pit: Distance to nearest Distance from foundation---l-A --------- Distance to nearest lot iine--.5— <br />Number of pits ----- ----- -------L ning maferia6 --- X--/.O--X-- meter----------------------- Depth ----_f - ------------ <br />Distance from nearest well._______________ Distance from fou' materia ------ ------------------- <br />Cesspool: foundation_ -------------- <br />Size: Diameter ------------ - : -------- --- Depth ---------------------------------------- ---------Liquid.CapacitY <br />---.gals <br />Privy: Distance from nearest well ------------------------------------- ----------- Distance from nearest building.________.._______________-_ .-. <br />❑ Distance <br />uilding--------------------------------Distance to nearest lot 11in -------- <br />-------------------------------------------------------------------------------------------------------------- ------------ <br />Remodeling nd/or repairin fcle,cni------- - ---- -- <br />(2 - ------------------- <br />n <br />lew 1-4- <br />--- ------------------------------------ --------------------------------------------------------- ----------------------- - <br />11 -- <br />--------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- -------------- <br />I hereby certify that I have prepa-red this application and that the work will be done in accordance with San Joaquin County <br />ordinances, state ws, and rules andli ulat*ons of the San Joaquin Local Health District. <br />(Signed) -"L - -- --- ------------: ------ ------------------------------------------------------------------ (Owner and/or Contractor) <br />�nd,l r +uaT ons . of 66 <br />$y:.- ------------------------------ Ti <br />--------------------- ------ ---------------------- __ ------------------------------------ itle) ------------------------------------ ------------------ ----- <br />(Plot plan, showing size. of lot -location 'of system in relation fo-wells,.,6uildings, etc., can bea�ced on reverse side). <br />pj <br />FOR DEPARTMENT USE ONLY <br />APPLICATION ACCEPTED BY---------- ----------- DATE-- <br />---------------- ---------------- ----------------- <br />------ ------ --- --- - --_ ------------------ DATE-- — --------------------------- <br />REVIEWED BY-------- ------------------------------ - <br />BUILDING PERMIT ISSUED-------------------------------------------------- .... _( ------ ----------------- DATE <br />Alterations and/or recommendaf ions; ----------------------------- <br />------------------------------ <br />ti <br />--------------- ------------------------------------- ­ ------------------------------------------------------------------------------------------- ----------------------------------------------------------------------- <br />----------------------------------------------------------------------------------------- m ------------------------------------------------------------------ ----------------- ­ ----------------- ---------------------- <br />-------------------------------------------------------------------------------------- ---------------------------- ------------ ---------------- ----------------------------------------- ---------------------------------- <br />----------------------------- --------------------------- /-./ ----------------------------------------------------- --------------------------------------------------------------------------------------------- <br />FINAL INSPECTION BY: -__________ 1-1 - Date ------ 57 <br />SAN JOAQUIN LOCAL HEALTH DISTRICT <br />130 South American Street 1300 West Oak Street 132 Sycamore Street 814 North "C" Sfreaf <br />Stockton, California I Lodi, California Manteca, California Tracy, California <br />ES -9-2M Revised 1.57 F.P.CO. A <br />