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APPLICATION FOR SANITATIONY +�� -�-� PERMIT Permit No. ....._•-•-----•----•---- (Complete in Duplicate) Date Issued 2040 to IFV Application is hereby made to the San Joaquin Local Health District for a permit to con truct and install the w r 'n s _. This application is made in compliance with County Ordinance No. 549. OB ADDRESS A AT p----- --- --- --- -_.r---•-•-•---•_r_---- - _------- -f•- -`7�Y-----.---------14 ------ Owner's N �>yr�^ "`' ---- - ---- ---- rs Phone ---------- Address-_ ----•--- -�2� Address 1 _.. ........ _. .... / ----- ------------------•---------- •--------•-----.----- ---------•----•--•--•- Contrac is Name -- ------------ -------------_ y' G-- --•------ ---------------•------------------------..__ Phone__ ----------------------- Installation � _____ ____�__f_ �✓ _ -; Installation will serve: R-e ience � A artmen Abuse Commercial � V / \ p ❑ ❑ Trailer Court ❑ /Motel Q Other ❑ Number of living units: _ __ Number of bedrooms�_. Number of baths ./-____ Lot size ____1__`^ - .�---------------------- Water Supply: Public system ❑ Community system ❑ Private Depth to Water Table ft. Character of soil to a depth of 3 feet: Sand tni Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe ❑ Hardpan ❑ Previous Application Made: Yes F] No New Construction: Yes No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: )) , T = (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tank: Distance from nearest wel _,_.___..Distance from'founda tion_ ___.-_--Mate/rial ---�C cz2>_�.�------- ------------ - Nc. of compartments___ --------------Sire-�.`t , 7 V__Lrquid depth_-2 j Capacity--•-----F--�.--- Disposal Field: Distance from nearesptt weli_�1��_ ___Distance from foundation_ ___p___,____.Distance to nearest-lot line___.----- Number o7 lines------C-______ ------------------Length of each line------------ - �__--.Width of trench------- --•- yy Type of filter matena�_ . •------- -------Depth of filter material---�_�---------Total length------------; :� ______________ Seepage Pit: Distance to nearest well----------------------Distance from foundation--------------------Distance to nearest lot line----- ----------- ❑ Number of'pits----------------------Lining material-----------------------Size: Diameter---------------------- Depth------------------= ------------ Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material-------------------.-----------------i_ ❑ Size: Diameter-------------=------------------------Depth------:------------------------ --------------------Liquid Capacity--.-•-----------------------gals++ Privy: Distance from nearest well----------------------------------------.--------Distance from nearest building ❑ Distance to nearest lot line___________________ Remodeling and/or repairing (describe)__________________ n { +'____....___________--------------------------- .c '-------------------------•---------•-•---------•--------- ----------------------------.--------•----------- ----------•---•------------•-- -----------••-•-----------------•----------•---------------•------------:-----------------------•-•------- --------- I ---------•--------------•----------- -••--------------------------------•----•------------•----------•--•----------------•---- --------------------------------------------- ---------- j -------------------•----•-•------------•--••--------._._..--------•--------------------------•----------------------------------------•------ ---------------------- -- ------ I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin Couni ordinances, State laws, and rules and regulations of t elan Joaquin Local Health District. {Signed} y - -�- - ------ ---------- --. ------ ----------- --------------------------- -(Owner and or Contractor), gY• ......•••• - Title -iii c : � — t (Plot plan, showing size of lot, loca06 of system relation to wells, buildings, etc., can be pla�d on reverse"iide). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY BUILDING PERMIT ISSUED -----------------------•----------- DATE---------- ` REVIEWED BY-------------------------------- ------ ----- DATE------------------------------------------------------------ ------------------------------ ------ DATE------------------------------ ------------------------- Alterations and/or recommendations----------------------------------------------------------------------------------------------•--- - — = -----------------------------------------------------••-•------------------------------------------------------------------------------------------------------------------•------------------------------•--------------- •---------------- (.3- . 1 S ----------- ------ ------ -------------------------------------------------------- --------------------- ----------- --•--------------- ----------------------- FINAL INSPECTION BY:.-------- -- • - Date 4 SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Street 914 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California ES-9-2M 10.52 Revised W-2100