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FOR OFFICE USE: Permit No. ---_• - II'- APPLICATION FOR SANITATION PERMIT f 7.2 3 (Complete to Duplicate) Date Issued ------------------------------ -------- This Permit Ex fres 1 Year From Date Issued Application is hereby made to the Son_Joaquin_Local Health District for a perAit to construct and install the work herein described. This application'is made in compliance with County Ordinance No. 549 106 ADDRESS AINND LOC� V Xv. 1T10._- �� --- C> >��._." X-- ------ )a Owner's Name------- �--�- --------- " - - - -- ------ -- -- - Phone--------------------------------- Address -------------------------------• Address. ." � -- -- --------------- Contractor s - , Name-----=- ©`�=-�------ �- ---------- ------- --•----.---•--------------------..__.._. Phone----------------------------------- Installation will serve: Residence Department House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ OtherI 'r ❑ Number of living units) _1_____ Number of bedroomsn . Number v'baths ---a Lot size ---1_,3-�'t---x-------- �____-_.__-__ Water Supply: Public system� E] Community system E] Private epth to Water.Table ft, Character of soil to a depthlgrof 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam 1(6 ❑ Clay ❑ Adobe [[Fardpan C]Previous Application Made: yes,date_...__.__-_.__.._) No New Construction: Yes No ❑ .FHA/VA: Yes [jNo ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or ce spool permitted if public sewer is available within 200 feet.) r -- Septic nk: Distance Cfrom nearest well------,a0._------Distance from foundation__/4_____.__..Mat�r�l-_�(�__�________________---___________. No. of elompartments___:�.�.____.__._._-Size_____,�__Cz__ ._4� Liquid depth____�7__/__.� ��_Capacity_______________________ Dispos field: Distance from nearest well.._. _____ Distance from.foundation----/_L0 ____.Distance to nearest lot line_____________ Number;"' umber Iof lines_____ __.___Length of each line____/._ -.Width of trench____ _________________ Type of filter materiai___ 2<_ °'be th of filter material___. _ p--�f Total length___-.__,1�_1✓..__�_G_ __ Yp i -- ---` p �4� - -- -- f' 1 i � � F Seepag if: Distance' to nearest well-------) __-__Distance from foundation___ _ _____Distance to nearest lot iine�.______-. Numberof pits- _ ._ ..Lining material____� ___..Size: Diameter.__3.�� ...-__De th-.-.l Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material---------------------------------- [❑ Size: Dia€ eter------------- --;---- --------------Depth-----------------------------------------------------Liquid Capacity-.-------------------------gels. r Privy: Distance from nearest well___-------_----_____-------_---------------------Distance from nearest building----.------------------------------------- Distance ___.________________-__..____.__._. ❑ Distance'to nearest lot line-----------------------------------------------I---------------------------------------------------------------------------------------------- -- ---� - Remodeling and/or repairing (describe) � ------------------- ---------------- � w -- ---------------- - -- -- ---------------------------------------. ---------------------------•----------------------------- ---------------------------•----------- ----------------------- -- ---------- '----------------------------- -------- ----------------------------------=---------------------------------------------------------------------- --------------------- I hereby certify that I IP a prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State laws, % rul s and regulati n of the San Joaquin Local Health District. �l k (Signed} ----------- /� (Owner and/or Contractor) Ao e ---(Title)- �/ .By--------------- I�--... ---- -- -------- ------ (Plot plan, showing size of lot, location stem in relation to wells, buildings, etc., can be placed on reverse side). . �I FOR DEPARTMENT USE ONLY mss-=-r 1J �. APPLICAT€ON ACCEPTED'IBY----------- ------ DATE------- - -�-- ------ --- -------- ----- --- REVIEWEDBY---------------------i------------------------------------------- ----------------------------- ---------- - --------------- DATE-------------------- BUILDINGPERMIT ISSUED11--------------------------------------- ---------------------------------------------------------— DATE------------ ---- Alterations and/or recommendations•_----- _) _-'._/_ 6 [=_r_.______. �_____�"L-`___------_"` "�-'� �_.._- , --- i_ZC------------------------------------------ - r . --------'`----- - Il. ilj' ------------- --------------------------- 11------------------------------------------------ -- ---- ---- 1i� FINAL INSPECTION BY:�--- ----•------restOakStreet '� Date..-.-----��----�-.--------- ,a 1 .� w SUIN LOCAL HEALTH DISTRICT 4 1601 E.Hazelton Ave. * 380- 124 Sycamore Street 205 West 9th Street 41 Stockton,California Lodi,California Manteca,California Tracy,California