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FOR OFFICE USE: ----------------------------------- ----------------------------------- ------ APPLICATION;'' FORM SANITATION PERMIT Permit No. . --- L�V (r7'. .___..__ (Complete in Duplicate} --_.. '; This Permit Ex ires 1 Year From Date Issued Date issued __ __w- _ ) Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described. This application is made in compliance with County Ordinance No. 549,� rV/?yam-/ p JOB ADDRESS AND LOCATION n_ Si_'1 �__ _ �' / V /� Owner's Name-- --------------i-------------------------------------------------- ------ Address------ ----Address------'titf.. h� 1 {-` ------------------------------ I Contractor's Name__----. .. _ ----------------------------------------- ---- Phone----------------------------------- _ Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ JOther ❑ ENumber of living units: ----l Number of bedrooms'-3--- Number of baths --; Lot size -—__.-,--__.-___---_ Water Supply. Public system ❑ Community system ❑ Private [+Depth to Water Table _'1--5'ft. -� Character of soil to a depth of 3 fee+: Sand E] Gravel E] Sandy Loam F] Clay Loam [B<Clay E] Adobe E] Hardpan ❑ s Previous Application Made: (If yes,date_------------------) No ❑ New Construction: Yes [Er'lNo ❑ FHA/VA: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool,permitted if public sewer is available within 200 feet.) 112 J. t Septic Tank: Distance from nearest welL_J7a_____.__Distance from foundation- 1Q-----.--.Material_- '___________________________ __ No. of comparfinents-----C�:.-.-------- Size_ .��_ __�(. _Liquid depth--.---��-----------------Capacity./0` - --_- Disposa! Field: Qistance from nearesf well_. _____...Distance from foundation_. ___.-_---_Distance to nearest lot line, ------------ I Number of lines-------- ...... _--.._.____Length of each line------ ___? .._.Width of french-----�i '__.___________.. ; Type of filter ma- of filter material---149......__.._..Total length____ U__..__._..___.______.__� Seepage Pit' Number of its-rest Z..-_- _-_. Linin material--- Cesspool: a#sfam_S2._ foundation---_p�a__._. Distance to nearest lot line___-._____--- $ i Qe Depth Distance to nearest well __Q..Q.__g Distance fro�rr�'r�,Size: i3iameter._.._.�'�__.�. p - o Cess ool: Distance from'nearest well-----------------Distance from foundation._.................Lining material--'-.--------------------------------- E1 _°-----_-_._.- - ❑ Size: Diameter------------------ -=-- •------------Depth---------------------------------------------------Liquid Capacity---------:------------------ga Priv Distance from nearest well_________________ _ -------------Distance from nearest buildin ❑ Distance.to nearest lot Iine------------------------------------------------------------------------------------------------- ------------ -- -------------- -- - ....... Remodeling and/or repairing (describe)______________________ - --------------------------------------------------------------- -------------------I---------------- --- 4 ----------------a---------------------------------- ----------------------------------------------------------_----------•---------------•------------------------------------------------------------------ ----- ------------------------------------------------------------------------------------------------------------------------------------------------- - --------------------- --------------------- I ------- ----------- --------------------- I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County f ordinanceVSTfaff laws, and rules and r gulations the San Joaquin Local Health District. IV (Signed} -t.0 .. - ------ ------- ----------------------------------------- ------------------------- -----(Owner and/or Contractor) ____ - I 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 LY DATE REVIEWED BY------------------------- ----------------- -------------------------- --- --------------- APPLICATION - -- APPLICATION ACCEPTED DATE BUILDING PERMIT ISSUED----------------------------------------------- ----------------------------- DATE------------------------ -- - - ------------ ----------------- Alterations and/or recommen ns__ _______________ ___ ______ __ -- ------------------------------------------------------------------------------------------------ --------------------------------------------------------------------------- -. -------------------------------------------------------------------------------------------- ---------------------------------------- ------- ---------------------------------- ------------------ --------- ------------------------------------------------ -------------------------------- ----------- ------- -------------------------- -------------------------------------------------------------------------------------- -- - - - ------------------------------------------------------------------------------------------------------------ i FINAL INSPECTION BY:------- --- Date-------- 1 T SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.fla:eltan Ave. 300 West Oak Street 124 Sycamore Street 205 West 4th Street Stockton,California Lodi,California i�: __ Manteca,California Tracy,California F.P.C U.