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OR OFFICE USE: U - - 3. � ------------------ -- ?------------- rr�� I _______________...---.-..---------_ __._.....__.___. APPLICATION FOIL SANITATION PERMIT Permit No. 12.Z42Z__._ ---------------------------- --- -------------------- (Complete in Duplicate) ----- This Permit Expires 1 Year From Date issued Date Issued �Q_-_l�—_ �'� Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the worts herein described. This application is made in compliance with County Ordinance No. 549, JOB ADDRESS AND LOCATION--- ` ------------------------------------- ---------- �l/Owner's Name--- ` .. ---- ------------------------- ------ �--------------------------------- Phone---�"-� ----_-� �- Address _ -------------------------------------------------------------------- Contractor's Name------oe!�) --- -----e1' /- / ?tlTl-------------------------------- Phone,--Zp Installation will serve: Residence X Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: Number of bedrooms -------- Number of baths -------- Lot size --.-----_._____..____------------------------------------ Water Supply: Publics stem Community system .�...—T�' - pp y: y [] y y ❑ Private ❑ Depth to Water Table-- ft. Character of soil to a depth of 3 feet: Sand ❑j* Gra el❑ Sandy Loarn 0' Clayi o rri ❑ Clay ❑ Adobe ❑ Hardpan ❑ � �•• w/ Previous Application.Made., f..y..es,dgtei--___ T )_No,[:]_New Construction: Yes ❑_Lo ❑ FHA VA: Yes ❑ No ❑ 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 founclat'on---/Q_r_____- Materia L, No. of compartments,------------ --------Size------f --� Liquid depth---- -------- ------------Capacity _ _ _ I< Disposal Field: Distance from nearest well------ -------- _DIsft nce from fo`undation'""7-7.7-'_--.-.Distance to nearest lot line----------------- t 'y !'i-M ❑ Number of lines---------I-------------- 1-----Length of ea`hline-'t ----------------!.....Width of french----------------------------------- Type of filter material_____________ ____t-----Depth of filter material---------------- ._--_Total length---------_________.________.._-.---------- t ! ' Seepage Pit: Distance to nearest well---.---- -.-___Distance from foundation--------------- Distance to ❑ Number of pits.-- ------�-----------Lining material__'_.._�.._s...___ Siie: Diameter-------------- --------Depth----.---------------------------- Cesspool: Distance from nearest well.----1..-.f-__.-Distance from foundation-------------!_.._.Lining material-------------------.---------.-------. ❑ Size: Diameter 1------- 1 Depth-------------- �Liquid Capacity- --------------------------gals. }--- -� i, Privy: Distance from nearest well------_ .--.-----____________________Distance from .nekest building---------------------------------...__._. ❑ Distance to nearest lot line {--- ----------------------------------- ---------------------------- --------------------------- Remodeling and/or_�r pairing (describe):___._ P ---------------------------- ------------------------------------- --------- --------------- r---------f--------------------------------------------------------------------- ----- 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 rul s and regulations of.the San Joaquin.L`ocal Health District. z / _ `m -:- s: / ( O ner and/or Contractor)(Si (Signed) -- -- - f _: -____._ - _ r _ � BY: {Title} ; -------------------------------------------------- ----- -------------------------- -- ---- - (Plot plan, showing size of , location of system in relation to wells, buildings, etc!, can be placed on reverse side). �, (AAN + . FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY---- ---- �------- ----------------------------------------------------------------- DATE---- REVIEWED BY------------------------- ------ ------------------------- ------ DATE----- ------ BUILDINGPERMIT ISSUED----------------------------------------------------:_----------------------------------------------- DATE.----------------- ----------------------------------------- Alteratior}s,an or recommendations--------------------------- -------- -----.- ;il--------------------------------------------------------- -- -- ---- -- ------- - ----- _------ ---------------- �' ' - ----- --- FINAL INSPECTION BY:----- - _ ---- - - ------ ----------------- Date-----`d -- �' SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.ffaselton Av*. 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California Lodi, California Manteca,California Tracy,California