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FO OFFICE USE: IIS APPLICATION OI= R SANITATION PERMIT Permit No. ..��•.-_••---.� - --------------- ----------------- -- ---------- _-_.___.,_� (Complete in Duplicate} / ----------------------- ------------- Date Issued _ 1- _. - . � T This Permit Expires 1 Year From Date Issued ------------------ - - ,r Application is hereby made to the Sen Joaquin Local Health District for a permit to construct and install the work herein described. dl� This application is made in dompliance with County Ordinance No. 549. p ' f JOB ADDRESS AND LOCATION --- - `"��T ` I - - ---------------------- ----- -------- Phone__ . 6_?�_-X Owners Name-"---------•-•-• ---- ------ Address--------•-•----------------- I --- `---------------------------------------••-•---------------------------- Contractor's Name--------------II" -- -� � •------- •-- --------------------------------------------------------------- Phone------------------------- --------- III Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: --- Number of bedrooms --- - Number of baths __k_-___ Lot size ----__ _ ___ -.--------- Water Supply: Public- system ❑ Community system ❑ Private DR Depth to Water Table (0S- ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe Hardpan ❑ I Previous Application Madel(if yes,date--------------------J No ❑C New Construction: Yes ®, No ❑ FHA/VA: Yes ❑ No TYPE OF INSTALLATION AND SPECIFICATIONS:, a (No-septic-tank-or-ctpsspool-permitted-if-public-sewer-is-available--within-200-feet:) Septic Tank: _,Distance from nearest well--Z_DQ4____Distance from foundation___ _ �___------Ma�eria}__ _�}:IAC_.( -� -F--_-___----. No.�of.compa-,fitments-----:Z----------t---Size__ .i_K_�,x-S-'__Liquid depth_---.k!�------------Capacity---� - -- 1 Disp sal Field: Distance from nearest well:--SV__._Distance from foundation -______.__Distance to nearest lot line-i��_________ { Numberbof lines----- �"-----------------------Length of each line------6d----------------Width of trench-------z-4-----------------.- r ` .e--of filter material�r_.__�OcL-c..__Depth of filter material_____I_-_& -- - ------- length_ ________________________ =Seepage Pit': DistarA to nearest well_.___________________Distance from foundation-------------------.Distance to nearest lot line------------- J� u#�❑ £ Numbed!of pits111 ------------Lining material------------------- - Size: Diameter-----------------------Depth---------------------•----------- r ; i Cesspool: Distance from nearest well_________________Distance from foundation------------------- material--------------------------.--_____--- ,r Priv D stanDella fromr nearest well Depth - Liquid Capacity gals. ^ y Distance.from nearest building------------------------------------------ Q ❑ l Distance to nearest lot line--------- -- Remodeling and/or repairilg (describe)---------- ----------------- ----------------------------------------------------------------- ------------------------------ -----=--------- Ilk------------------=---------------------------------------------------------------------------------------------------------------------,-------------------------------------- __.. —__QA------------ e-------------- -------------------------•- ------- O� 1.p = — — - ---------------------- ------------ I hereby certify that 111have prepared this application and that the work will be done in accordance with San Joaquin County ordinances. State laws, and rules and regulations of the San Joaquin Local Health District. (Signed)-- '-'r7�------�� --- - � ------- -"�- -- -- --- - �---- =---- ---- ----- -- --------------- •- -----------••----- ----(Owner and/or Contractor) !fib By:--------------------------- --------- [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 ACCEPTEDy.BY_ 1' �5 --_-._..--_---------------------------------------- ----- DATE----�- z-$.---� -j------------------------- REVIEWED BY III . # DATE-------------------------- ------`----- ----- - - - - BUILDINGPERMIT ISSUES_____`---_'-*-----x------------------------------------------------------------------------------- - DATE--------------------------------------------------•------ Alterations and/or recommendations:--- ___.____.__-__ .nx ------------------------ --------------- • --------------------------i------------ ---------- ------ - - ------------------ - -------------------- ---------------------- -- ------------- ....... ------- .___------ ----------- -------- - 1 . FINAL INSPECTIONBY:..__C_.._ . �----------- -------------------- Date -----�'' '4 ' ---------- - ------------------------------- CA SAN JOAQUIN LOCAL-HEALTH DISTRICT 1801 E.Hasalton Ave. 300 West Oak Street _,"124 Sycamore Street 205 West 9th Street I Stockton,California. Lodi,California Manteca,California Tracy,California E6 9 REVISED 8-59 3M 3`6II F.P.CD. '