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APPLICATION FOR SANITATION PERMIT Du Permit No. 1- •- 1 licate Date Issued ----- 1 (Complete in D permit to construct and install the work herein described. Applica-ion is hesemedeaaeco compliance with Countyto the Seri Joaquin a0 Ordinance NoC 549.a p , This application '"�'m -- --------- ------------••--- f / -------`----------------------•- ��, . _/__ ---- -- =- JOB ADDRESS AN LOCATION.- --- ---------- P o ------------ --- --- ----- '! ------- Owner s Name_____.__ I 1 : 'y< ---------------- Address------------------Y'��-- on Contractor's Name-_.__-_ � -�-- ' A artment Hausa ❑ Commercial ❑ Trailer Court Motel ❑ Other ❑ W! Installation will serve: Residence p . _. Number of bedrooms --A- Number of baths ---A- Lot size ___-- _-,•j�---- Number of living units: - Private ❑ Depth to Water Table __ (/ ft. } : Public system �mmunity system ❑ clay Adobe ardpan ❑ 4 Water Supply: Gravel ❑ Sandy Loam❑ Clay Loam ❑ Y ❑ Character of soil to a depth of 3 feet: Sand Gravel Construction: Yes ❑ No � t � Previous Application Made: Yes ❑ No 2/ �111111- (No TYPE OF INSTALLATION AND SPECIFICATIONS:septic tank or cesspool permitted if public se stanceafomfouda foundation -Material__._------------------------------------------ ---------------------- ---------------------------- Septic T nk: Distance from nearest well---------------- Liquid depth--------------- Capacity-----------•-- ❑ No. of compartments---------- ---------------Size--------------------------------c ach line------------------------------Width of trench ------ Disposal Field: Distance from nearest well______________-Distance from foundation____-___------------Distance to nearest lot ine------_._____.___ Nurrmber of lines--------------- Length'o ef ❑ De th of filter material------------- Total length--.---_-.------- �� d0 Type 01 filter material-------------------� p fours ation.._._�_0--• Distance to nearest lot 11.22-i----------- / [ ----Distanc� ar� -f-------Depth ---------------- it: Distance to nearest well-_.-_(A_E7----- C Seep it: � Size: Diameter__._t�3 P Number of pits------ -- -Lining ma#erial______-- - - - Distance from nearest well-------------- - Dssttace from foundation------------ -----I'`quid Capacity-_.-----------------------•gals. Cesspool: -----De � Size: Diameter------------------------------ -- - - - '- µg---------------------------------------- _ Distance from nearesT building � Distance from nearest we ------------------------------------------------ ---- --- ----- ---- ------�-�- -------------------------------- Privy: ---- -- - --= ❑, Distance to nearest lot line---------------------------------------- --------- - I - - •----------•--•-------------------•------------------------------------•- ---------•------ / airin describe7:------------------------------- -•---•--• ------------------- = Remodeling and/or repairing r -----------•------------------------------------------ --------------•-------------------------------------------4----------------------------------- in County application and that the work will be done in accordance with San Joa u---------------------- I hereby certify that I have prepared this app ordinances, State I and rules[and regulations of the San Joaquin Local Health District. and/or Contractor( Ir -------------------- Sined -------------------- --------------------------- ----( 9 Ti ¢y_________________ ______ ___ _____ (plotIan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). y ( r FOR DEPARTMENT USE ONLY ------------------- DATE-------- --------------- -------- ------5 ; ------------ ------------------------ --------------------------------------APPLICATION ACCEPTED BY------------------------------------------ ----------- ------ ----- - -----.----- DATE BY. = ------ DATE--------- ------------`,--�--------------------------------- REVIEWED --.--------------------------------- -- BUILDING PERMIT ISSUED--------- ----- ---------------•------------- Aiterations and/or recommendations--------------------=4-•---- - •- ----- -- -- ----•----------•-----------------•--- -----------•---•--• - -------_---------------------------------•---- ------------- ------•-----•--- -------- Date---------------------------------• �-�- ---�- - FINAL INSPECTION BY:---=---=- ----�---- ------ - I _ SAN JOAQUIN LOCAL HEALTH DISTRICT "�•" � i32 sycamore Street 814 North "C" Street 300 West Oak Sheet Tracy, California 130 south American Street Lodi, California Manteca, California Stockton, California cc—o-7M Revised W-2100