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rvKvrrlt,.t VJt: I -------------------------------------------------------- + I _____________________________.______-_._..________.____ APPLICATION R SANITATION PERMIT Permit No. ..........: .. . _ ------------------- ---------------------------------•-•• (Complete in Duplicate) S. ------------------------------------------------------ This Permit Expires 1 Year From Date Issued Date Issued Application is hereby made to the San Joaquin Local Health District for a permit to construct and install# work ereifi des gibed. This`applicdfion.is made.in complia ce.with County Ordinance No. 549. - ! JOB ADDRESS AND L TION_. - Owner s Name-------- I - -- .. -------- ....................... Address............. --- •--..._...... Contractor's Name----- --------- ----•------__----•- - -----------------------------------------•---... ---------------------------. Phone- .........................._•-...... Installation will serve: 'Residence J1 A riment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other 0 Number of living units: ---/--. Number of bedrooms . L .3Number of baths ........ Lot size ---•---�-------�..............�----------•---..:._ Water Supply: Public system ❑ Community system ❑ Private Depth to Water Table.-ft; Character of soil to a depth of 3 feet: ;Sand ❑-Gravel ❑ Sa dy Loam ❑ Clay Loam ❑ Clay ❑ Adobe Hardpan C] Previous Application Made: (If yes,date__._..* _______._1 No New Construction: Ye � No ❑ FHA' /VA: Yes ❑ No TYPE OF INSTALLATION AND(SPECIFICATIONS: . F (No septic tank or cesspool permitted if public se er available within 200 feet.) Septic T n r Distance fro�m.t+earest well- _". is an from foundation..........----------Material--_•_____-_...______.....__........._..__..._.... ❑ No. of comp`ar,mems_. .�Size.-• Liquid d pth_..- f Ca aci LL P ty-----------•.-_-....... 9` Disposal Field: Distance.from neatest well-�_d�.--Distance from foundation- �o___Distance to nearest lot lie •-• - Number ofxlines�__��•_.___--�• 1.Length of each line____1-C,�._�----..�__.Width of trench....... . 1�--•-----•-•-.• � o,_ ,_Width of k r m terra. _._ ___.._•,_- Depth of filter material-_____ -------Total length__=___ _-®___--___.-._••_••_ Seepage Pit: Distance ,to nearest well______________________Distance from foundation--------------------Distance to nearest lot line___-•_--_•_.-_... 4 I ❑ Number of pits1--..."-----------Lining material-----------------------Size: Diameter.--------•-------_---.De- th---..._..---.---.---_. fv I Cesspool: Dista�nce'lfrom neare t well_________________Distance from foundation--------------------Lining materiel-_____.:__..___-•_ Size blameter_,::..: - ----------•-------------Depth---------- --------------------------------•--------Liquid Capacity_ PrivDist 'e r"'"°� °' .` y' ancefrom nearest well________ g. --_-_._.-___Distance from nearest buildin ❑ Distance to nearest lot line-. :. Remodeling and/or repairing (describe):_}_________________________________.___---------_-_ .................I------------------ ....... -------•--------- ------•---•--------------------•--------------- t ------------------ ----------------------.___.._______--__:__.---------------------------------.__•---•-•-. } , I hereby certify that I have piepared this application and that the work will be done in accordance with San Joaquin County ordinances, State laws,land rules and regulations of the San Joaquin Local Health District. Z(Signed).. MX-L- .------------------ ---------------•----------------------•----------------------••--------------(Owner and/or Contractor) $Y• ---------------- (Title) ... (Plot plan, show nig 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----- -------------------E ------------------------ ---------------------------------------- DATE--------•----------- i REVIEWED BY-------------- -------------------------•- - - . DATE------•-�' i----- .3 ! _- -••--•-------------- , BUILDING PERMIT ISSUED- f------•-------� --- --•--...... — � - - ---------.. DATE-•-----•----...... — Alterations and/or recommendations_ I -------•-------------------------._._...------. -_,_...-':----- � }•--•---------------- it 011 --•---- i --------------- ---•-------- t ---------------------------------•------ t FINAL INSPECTION 1BY------ --------- --------------------• ----- Date---------------- 2, 3 SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California Lod],California Manteca,California Tracy,California Eli 9 REVISED 8.89 21A 5-61 ATLAS