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VUK UFrIC-t Ubt: --------------------------------------------------------- APPLICATION FOR SANITATION PERMIT Permit No. ------ ------ --- ------------ --- (Complete in Duplicate) _______________________ 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 a work herein desc1 ed. This application is made in compliance with County Ordinance No. 5449. JOB ADDRESS AND LOCATION '-----� ---G�L--------------------5----C----G------ e Owner's Name------- r-----.D.fve/t�- �� ------------ Phone--------------------- -----•------------------- --------------------------- Address 1 -- l -• --••-_�C--- - ------- ------------------------------------------------------------------------ ------------ - -- ----------- Contractor's Name-------- -----`-- •------- --I-------------- Phone_lk;a*',6o Installation will serve: Residence []/partment House ❑ Commercial ❑ Trailer Court ❑ Motel P Other ❑ Number of living units. _1__._ Number of bedrooms Number of baths ___j_ Lot size ___-.. �'_.._ ____._/ L�________________ Water .supply: Public system ( !k Community system ❑ Private ❑ Depth 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: (If yes,date ________ _________ 1 No ® New Construction: Yes ❑ No 5j_—FHA/VA: Yes ❑ No [fir TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tank: Distance from nearest well-----------------Distance from foundation--------------------Material.__..__-_...__--__.._-------_-_--------_________- ❑ No. of compartments-.- - - �------------ ----Size------•----------- -------------Liquid depth------------ --------- -- Capacity---------------- Disposal Field: Distance from nearest well-_-_.....__._.._Distance from foundation--------------------Distance to nearest lot line_._____________.. ❑ Number of lines-----------------------------------Length of each line-----------------------------.Width of trench----------------------------------- . Type of filter material-------------------------Depth of filter material---------------------.-Total length_____._---------________------__--_-______ 1� f � Seepage Pit: Distance to nearest well--_*7P- 0E-Distance jr foundation----�r -------Distance to nearest lot line_,5---___-._ .. - Number of pits-------- ------ ---Lining mat eriaL_�Y '-k_..Size: Diameter-3U--_ --------Depth-----_•'"z_ .,5—'_!�________.._ Cesspool: Distance from nearest we!€-----------------Distance from foundation--------------------Lining material------_....___._._._____________ ❑ Size: Diameter----- --------------- ----------------Depth_-----------------------------------------------------------------------------------Liquid Capacity---------------------------gals, Privy: Distance from nearest well -------------- --- --Distance from nearest bui4ding--------------------------------...___._. m ❑ Distance to nearest lot line----- - ---- -------------------------------------------- lj I Remodeling and/or repairing (describe) �------� -------------------- ------------------" ' ----------------- --------------------------------------------------- ------------I------ --------- ---------------------------------------------------------------------------------- '--------------•---------r ----------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------ ------•------- -------- --- - ------------------------------------- -- -----------------------------------------------------------------------------------------•-----------------------------(I---------------------I--------------------------------- I hereby certify that I have 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 S aquin Loral Health District. Si ned A e� { 9 } / /-sl-- - ---- D/y�s- �_ � r = wn and/ori Contractor) fly:---------- - ------ ----- -------------------------------------------- ------------------ {Title} -- ... ....... (Plot plan, showing size of lot, to anon of system in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY Gf APPLICATION ACCEPTED BY__________________ __ T ----= -- *� - ---- T f-- - - ------ ------�---------------------------------------- DATE-- -------------------------------- REVIEWED -- - ---- ---------------- REVIEWEDBY--------------------------------------------- ------------------------------------------------------------------a------------- DATE------------------------------------------------------------ BUILDINGPERMIT ISSUED------------------------------------------------------------------------------------------------------ DATE------------------------------------------------------------- Alterations and/or recommendations:--- -- ------- --- -- ---------------------------------------------------------------------- -----------------•------------------- ----------------:r ti ---y-------------------------------------- ---------------------------------------------------------- - -------------------------------------------- ---------- ------------------------------------------------------------- ---------------------------------------------------------------------------- ------------------ - ----------- ---------------------- ------------------------------------- .............. ----------------------•-------------------------------------------------------------------------------------- --- ----------------- FINAL. INSPECTION BY:-------- --------- ---- --------------------- Date-------------- -- ---- ------------- --------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Hazelton Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,California Manteca, California Tracy,California F.P.Ctl.