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ja' 1 APPLICATION FOR SANITATION PERMIT Permit No. Aaj .I__Y_ (Complete in Duplicate) �� Date Issued ._ y �---iS Application is hereby made to the San Joaquin Local Health Disf?ict`"oror!a permit tot "duct nd inBsttII 'work her in dei rib d. This applicatiori is made incompliance with � r' ��U � �� JOB ADDRESS AND LOCATIO _ i1�Fl q r �j. Owners Name ] -----------------------------------�--- ----------------'--- Phone_3"L,.0_. _ Con+ractor s Name -- ---------------------------------❑ Other ❑ Number of living units: __--� Number of bedrooms __2—. Number of baths �_.__. Lot size __S._1 J � < - . Water Supply: Public system ❑ Community system ❑ PrivateDepth to Water Table ____ __ ft. Character of soil to a depth of 3 feet: ' Sand/ Gravel ❑ Sandy Loam ❑ Clay Loam Clay ❑ Adobe Hardpan ❑ Previous Application Made: Yes [-] Na Q New Construction: Yes ❑ No [ FHA es W No ❑ T TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank.or cesspoai'permitted if public sewer is available within 200 feet.); y1` Septic Tank:�� Distance from nearest well ---__Distan ifrorti four�dafion____C_�----___.Mat ri�l___ ? �r =.�i uid'de th---------- ---.- - -- -E'6--- d No. of compartments______7�___._____Size.-.a�Xs-x� q �--- .________Capacity Disposal Field: Distance from nearest well---- .----Distance from founclatio _______ ________Distance to nearest lot line_.____-_--______ [� Number of lines-__-_-- r- _________ Length of each line_-_-_ ��i_ _______-Width of French f__. I__ l t Type of filter material____- L-__-Depth of filter material--__---R----_-_--__.Total length"_:_ ___.y_ _Q______________________ Seepage Pit:' Distance to nearest well----------------------Distance from foundation-------------------Distance to nearest loft line_-.__.____--_____ ❑ 11 Number of pits----------------------Lining material-----------------------Size: Diameter------------ �-------.Depth__..____---.--__-_-----_______.__ f� Cesspool: Distance from nearest well------------_-----Distance from foundation--------------------Lining material______.--------------_--____-__._._-. ❑ •�,`_}:;[1 Size: Diameter----- ----------------- -----------Depth-------------- -- ---- -------------------------Liquid CapacitY----------------------------gals. Privy: Distance from nearest ------- Distance-from nearest buildjn [❑ Distance to nearest lot line---------------------------------- ---------,-_----------------------- Remodeling and/or repairing (describe);-----------`-------------------------------------------------------=------------------------------------------------------------------------------------- ----•---•----- ------ - ------ ------------------------ -=-------------------------------------------------,-------------- -- I-----------------------------------------•------------------------------ ' ------ -i------ ------- ------•---- --- ------------` ----` -=------------------------------------------------•-----------------------------•-------•-----------------------=--------------------------------•-------------------------------- I herelay'certify..t�'t-1 have prepared this application and that the work will be done in alccordance with San Joaquin County ordinance State laws and rulesr',and`<regulions of the San Joaquin Local Health District.; (Signed)-14). -- . _ -------- � ----=''-- ------•----------------------------------------( t } Ownan / r Controcr} By. _ (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 ACCEPTED BY---------------- r ------------ ------ ----------------------•-------------------- DATE-------- -•- �} REVIEWED BY--------------------------------------------- -------- ------- ------------------------- - - ---------- - ----------------�------------- DATE---- --BUILDING PERMIT ISSUED----------------------- -- -- -- ------- -----------------------------------=_DATE------ �_. Alterations and/or recommendations:- --------------------------------- ----------------------------------------------------•-•-------------•----------•-----------------:_----------- ------- -------------- --- ---------- --- --- ------------- ------------------------------------ ---------------------------- , ---------------------------------------------------A---- _ --!------------------------------ ----------------------------- --------------------------- -- .__-__-________.__--_-. .__-. .� FINAL INSPECTION BY:--------4fti '- =v".. t Date---- _ SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Street 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy', California ES--9-2f4 , Reviseq 1.57 F.P.M