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FOR OFFICE SE: A`_ -------------------- `_ -------- --- --------..--------. APPLICATION FOR SANITATIQ N PERMIT _ Permit [. No. ... .... .1 f / ------------------------- --------------- (Complete in Duplicate)'� .-1-�---- � Date Issued -----..... ---..---------------------------------------- ------- --- This Permit Expires 1 Year From Date Issued Application is hereby made to the San Joaquin Local Health District for At{permit to construct and.install the work herein described. This application is made in compliance with County Ordinance No. 549. aA JOB ADDRESS AND LOCATION....../6QP h .......0.7f-----6,a..�l4_J x� e! ................................. Owner's Name......A),... ... !I /� -------------------------••-• ...... Phone...... ..... Address ..._.: Contractor's Name-------------- !..------------------------------------=--------------•-•----..._ - -------••----- Phone................................... Installation will serve: Residence [i/Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Othee❑ Number of living upits: _.4. Number of bedrooms S. Number of baths _/--- Lot size JUV .,lVe..I...*.................... Water Supply: Public Esystem 200*Community system ❑ Private ❑ Depth to Water Table Character of soil to a,depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe @3'T-ierdpan Previous Application Made: (If yes,date--------------------) No 2' New Construct(on: Yes ErNo ❑ FHA/VA: Yes P- No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: i �Alo sftpcic,jarA_or cesspool permitted if public sewer is available within 200 feet.) Septic Tank: Distance from nearest well._-_---....Distance from founcaiion__._.40 _.Material .``r � ��`�C!�........ No. of compartments------- ---------:_...Size �__ .. _....,r�'1`quid depth___'jE ............Capacity...JQ_&V.....:. Disposal Field: Distance from nearest�Jwell._._...---._Distance from foundaftun....o.-....Distance to nearest lotline...4........ [i?'1 Number of lines........A.4..._ Length of each line.._,P.S..I.............Width of trench....az.._......._....._..__.... Type of filter material. .--�A,- epth of filter material__;;./J--------Total length...... ff...................... Seepage Pit: Distance to nearest well........:--"--------Distance from Distance to nearest lot lin..tAr- ........ 91-11 Number of pits.....-oZ......_-_.Lining material---*.1_Lj/*-.Size: Diameter-...Y.3 % .....,Depth_-o7o�.__._•............. Cesspool: ,._.,-Distance.-from nearest_weiL............Distance from-.foundation :.:............Lining ma erial........I......................... ❑ 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):---------------- _-Q1P �< _...61 .......__.__•._-_...................................... -------------•--•--------------------...----------------------•-----•-•---------------------------------------•---•----------------------------------------•-.....................................-•---.................... . -------------•-•----------------------------•-----------------------------------------------------------------•---------------•------•--••---...------------------------------. 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 rulesand regulations of o-f the San Joaquin Local Health District. (Signed)..........................-••��j-� �s�A ---------------------------_+ -'-- --- - - - - - ------------ or Contractor) By:.......................................................... ..................................(riifle)----��1�:----------:...--- -- ------------- (Plot plan, showing size of lot, location of syst in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCT PTED BY._, .--- je :? � '- ---•-------------------•-•----......DATER--_, �!_-:.,.(p°�•---.......-....----- REVIEWED BY----------------------------------------- ............. DATE..... BUILDINGPERMIT ISSUED.............................................................._......=--............................ DATE............................................................. Alterations and/or cam endations:......................... ... ----------- r -------------------------------------- ------- --�-� -------------------------------------- --------------------------- ------------------------------------------ '_--...................... --------------------------•---•--•--------------------•----•-•--------- . .............................................. ----•-------...----.._...._. .............................................................................................................................................= FINAL INSPECTION BY:.----: - - ------------------- Date f — Imo....- Z_-------- -_--•---- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street — .AVA.Sycarnoro Street 205 West 9th Street Stockton,California Lodi,California Manteca,California Tracy,California ES 9 REVISED S-!t9 RM 5.61 ATLAS4 -