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FPR OFFICE USE: - ---=-------------------------------------------------- APPLICATION FOR SANITATION PERMIT Permit No. .12.2 ----------- ----------------- ----------------------- (Complete in Duplicate) Date Issued 2/ --------------------------------------------.--------- This Permit Expires 1 Year From Date Issued 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 Ordinaxce No. 549. JOB ADDRESS AND LOCATION -...... N C:14 Owner's Name---------f ---e- ------------/ K � I ----------------- Phone------------------------------------------ ---------------------------- ----------------- Address F r ---.. .&A .. _.�? 'L./�111� IPS dl��---------4f1//-------.� .............. Contractor's Name------ ,,.. � __ ---------------------------------------------------- Phone--------------------------------•-- Installation will serve: Residence Y Apartm nt House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Othpr ❑ Number of living units: ___,__ Number of bedrooms _A.- Number of baths J____ Lot size -----/nt_Q©O Water Supply: Public system ❑ Community system ❑ Private JX Depth to Water Table _5_- ft. Character of soil to a depth of 3 feet: Sand X Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe ❑ Hardpan ❑ Previous Application Made: (If yes,date---------------.----) No K New Construction: Yes ❑ No [TFHA/VA: Yes ❑ No F!r— TYPE OF INSTALLATION AND SPECIFICATIONS: - (No septic tank or cesspool erminedif public sewer is vailable within 200 feet.) t` Ci Ef4I �A H ISL Septic Tank: Distance from neares ell_________________Distance from foundation--------------------Material--------------.___._____--__________.___.___----. "6T I N&- No. of compartments--------•-----------------Size--------------------------------Liquid depth--------- ------------ ---Capacity------ ---------------- eispose d- Distance from nearest well----450----Distance from foundation...4-._______.Distance to nearest lot line 5__ Number of lines__________ ______________________Length of each line-------- __ n_____. l ------- Width of trench-------�'---•----------------••- Alk- Type of filter material__8_0_C1'_N____Depth of filter material_U2720--------.-Total length-----.------------ 1_________________ Seepage Pit: Distance to nearest well-----------------_----Distance from foundation....................Distance to nearest lot line----------------- EJ Number of pits---.------------------Lining material-------- --------------Size: Diameter-----------------------Depth-_-_-.____.__-__-__-____________ Cesspool: Distance from nearest well-----------------Distance from foundation-----------------_Lining material------.-.______-_______-._________._-. ❑ Size: Diameter----- ---------------- Depth---------------------------------------------------Liquid Capacity----------------------------gals. Privy: Distance from nearest well-------------------------------------------------Distance from nearest building----------------------------------.-___. ❑ Distance to nearest lot line----------------------------------------------------------------------- ------------------------ -------------------------------------------- Remodeling and/or repairing (describe):----------0-55_t-_631_L.l_T ______.O _____4't_Tf ,'i^....................... ----------l4DD----a6i--' tv'------ ---zT/-_! c $ -------------------------------------------------- ---------tiL.R O----- --------------------- ------------------ --------------------------------------------------------------------------------------------------------------------------------------------------------------------- - -------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State jaws, and rules and regulation;; of the San Joaquin Local Health District. (Signed)------- ------- ----------- - ------- - - ------ -------- --- ------(Owner and/or Contractor) By----------------------------------------------------- - ------- ----------------- ------ ----------- - - -- -- -------(Title)---- ------- ---- ------------------------------------ (Plot ------ -------- --------- (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 o APPLICATION ACCEPTED BY_ -----------I S 7t7A Q--------------------------- DATE-----��'_ T ��'------------------------ REVIEWEDBY-------------------------------- -•-------------------------------------------- -------- ----------------------------- DATE------------------------------------------ ................. BUILDINGPERMIT ISSUED-----------------------------------------------------------------------------•---------------------- DATE-------------_-------------- _.._.------------------ Alterationsand/or recommendations--------------------------- -------------- -----------•---------•------•---•------•------------••-•------••--- •.--------------------- -------•-----•---•---•-------------- -------------------- - ----------------------------------------------•--••------------------••- •--------------•---------- -------•---• ------•------•--------------------------------- -- - ------- =---------------------------------------------•---•---•------------------------------- ---------/------------------- FINAL INSP N B - 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