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F R OFFi USE: ------------------ v --------------------------- ----------- - --- --_- APPLICATION FOR' SANITATION PERMIT Permit No. .. � � _ (Complete in Duplicate) J �f l _. __ -._ �-_: . _ - Date`Issued •. -,.�=�f E -------------- ------ �" "� — TFiis Peiiniit Ex fres 1 Year _ 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 Ordinance No. 549. [ E JOB ADDRESS AND LOCATION- .......--� . - -°------/ ........... ------------------_ ---c/zla_ .---- Owner's Name----•---... -------------- - �/..1�'1 r �`a---------;:------------------------ -------------------------------------------- Phone.................................... Address ............r } --3 ---------= -•---------------•-----------------•-•--.•-----..--_-•--------.-__------------------------------ ....r_ Contractor's Name.... ..--•................................ I Phone.. G'? h_..Z. Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other [] 'Number of living units: _ ___ k......._ _ Number of bedrooms . .... Number of baths __ Lot size ....... _ ..-.r-4-.rte--�:��........ Water Supply: Public system ❑.. Community systm ❑ Private f Depth to Water Table .4.1Z?ft. Character of soil to a depth of 3 fee+: Sand ❑ Gravel ❑ - andy Loam ❑ Clay Loam ❑ Clay ❑ Adobb Hardpan ❑ Previous Application Made: (If yes,date--------------------) No New Construction: Yes f No ❑ FHA/VA: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: -) # {No septic tank or cesspool permifted if public sewer is ailabie within 200 feet.} f Septic `Tank: Distance from nearest well--S-02 -____-_Distance from foundation-----/,0--------Materig}___...� � �-�..... .............. No. of compartments ----e4--------------Size__ '-. _t'_.....,---Liquid depth__.;;7--------------Capacity....jrO6---..._. Disp sal Field: Distance from nearest well_-Z¢_-.......Distance from foundation....�r.........Distance to nearest lot lin.js5...__.._ Number of lines______ _________________Length of each line------ fWIrl idth of trench-------- Type of filter materialr-___�.?oe-ie__---Depth of filter material____Z------------_/ZTotal length.......1�C�_____--------------;:______-- Seepag'e Pit: Distance to neo er st well------------- ___Distance from foundation...............:....Distance to nearest lot line................. 0 [❑ Number of pits------------- material-----------1------------Size: Diameter------------------------Depth------ ------------------•----- `11 Cesspool: Distance from nearesf�well-------------°....Distance from foundation._.._______---___.Lining material_____________________________________ ❑ ! Size: Diameter--------------------------- I----Depth._.--------•---•-----_---•--•------------------•--Liquid Capacity---------------------------- gals. Priv Distance from nearest',well____1________1 -------------------- __._Distance from nearest building ❑ Distance to nearest lot: line---------------'----------------------- ----- -""-t Remodeling and/or repairing (describe):-:-----------------------------------------------------------------------------------------------.....----•--------••------... !.. � ,: � I i a i y P p pP L _ q -------------------------------------------- - ---- -- - ---- --- -- - ------ --- - ------ ------ -•-------- •_ ---••--- -- -- --••-•---------------------------------------- hereby certif-•that l have re ared this application and that the work will-be done in accordance with San Joa uin Co I ordinances, State laws, and rul '' regulations of the San Joaquin Local Health District. [ {Signed} ----------------•--••---------•----- --------- _5L--------------- (Owner and/or Contractor) sy--------••--•-•-•-••••-------•-••--•---•'-•,-•-.-_•.------ - ----- " '-�----- : _ (Title} �. cs-� ' (Plot plan, showing size. of lot, location of system in re Ion to wells, buildings, a ., can be placed on reverse side). ! z " FOR DEP TMENT USE ONLY APPLICATION ACCEPTED BY s.' DATE-.-.,/ / -------- REVIEWED BY........... - DATE - ---------------- ----------------------- BUILDING -----•----'---------- BUILDING PERMIT � � ISSUED---------1--------- K_--_-_---.-- DATE------------_------------------------- A* at* n an or recommendations--------------------------- -------------- ----------------------------•---•-----......-•------••-•----•----..........--------_------------ ..-. _.----•------•-- //._... -- . __---__---- _________________________ __ --.. ___________. -.-.- = I I _ r FINAL INSPECTION' BY-=------- ----------- -------------- ••- -••-•----- -------- Date---------- •-- - -----•_....__. ,z SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South kr4rican Street 300 Wed Oak Strut 124 Sycamore street 205 Wed 9th Street Stockton,California Lodi,California Manteca,California Tracy,California ES 9 REVISED a-99 YM 5-81 ATLAS