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FOR OFFICE USE: -------- -----___._ ----- APPLICATION T-QR SANITATION PERMIT hermit 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 insFall the work herein described. This application is made in compliance with Countyy Ordinance No. 549. JOB ADDRESS AND O ATION--- - Q �- �i'i�'' - ------------------------------------ ------------------------------- r+Owner's Name- ---- ------- C - ' ------ Phone--•--------------------------------- Address-------------------; ----- ----------------------------------------------------------------------------------------- ---------------------------- Contractors Name------------ .�-T~._�.-l%�--�'_ ---------------------------------------------------------------------------------- Phone.-_..---------------------------- Installation will serve: Residence ❑ Apartment House Commercial ❑ Trailer Court ❑ Motel ❑ Other [� Number of living units- ---- Number of bedrooms Number of baths --- Lot size __1hip-�1- -, ------------------------------ -- - -- - Water Supply: Public system Community system ❑ Private ❑ Depth to Water Table _4�_V Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe Hardpan ❑ Previous Application Made: (If yes,date-------- -----------) No [6r New Construction: Yes[�IVo ❑ 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 fowdation-----Xd5e-------Materia ------------- ®•� No. of compartments---J - Size- - 217Liquid`depth--.--_ ------------CapacityZ�-��----- Disposal Field: Distance from nearest well....'" Distance from founciatign---1/f- -...--Distance to nearest lot line-0--_ ( Number of lines-------- ------- Length of each line_-__ _ _ _-- _-. Width of trench_ -_-__ _______.___.--- Typo of filter material_- -/ f Depth of filter material_/� -Total length----,1, Q-_1 Seepage Pit: Distance to nearest yell__-_--.....-__Distance from foundation____&---------Distance to nearest lot_Ikne-3--l.------._ r Number of pits--. ------------Lining material--- Size: Diameter- ,._...- -_.___ Cesspool: Distance from nearest well-----------------Distance from foundation- .-...._--_- - material _-._.-.____-.-_________.____-_.-.-__. ❑ Size: Diameter------------------------------------Depth----------------------------------------------------Liquid Capaci'f ----- -----gals. Privy: Distance from nearest well______________________ _______________ Di�t`ance from nearest building.--------.------------------ _ ❑ Distance to nearest lot line----y--�------------------------------------ - ------------------,-�--- -�------------------- -----------•------ ---------------------- �l Remodeling and/or repairing (describe):-- -----------L�`� � 1 -- ..' � �� -------------------------•------------------------- -------------------------------------------------------------------------------------------------------------- ---------------------------- •------------------------------------------------------------------------------- ---------------------------__-____--_--_____--______----____----_-_-______--_-_-_---------.____-_-_----___-_----_-_---------_-_------_-_-------___-----------Y.-__-----__----------__-_-----------.------.-_------_---__.-._._ ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- P I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ID ordinances, State laws, and rule and regulations of the San Joaquin Local Health District. 1 (Signed)------------ --- - - - -----------------------------------------( rd�or Contractor) �/ Z = B ---------------------- - --------- -- ----- -. _Title ``(Plot plan, showing size of lot, location of syste relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY ` APPLICATION ACCEPTED BY '�-------------------------------- DATE------- - �`6�>------------ 'REVIEWED BY DATE / --------- ------ ---------- BUILDING PERMIT ISSUED-------------- ------------ ------------------------------ ----- -------- DATE-------------------------•---------------------------`�-� Alterations and/or recommendations:.......... /.r r>G/-..-- Z_. -- -------- -------------------- ----------1fL r- ' -f`�`^ �"� �--� ---.-------1_ t _------- ------------------------------------------------------------------------------------------ -------------------------------------------------------------- ------------------------------------------------------------------------.------ ----------------------------------- - ----------•----- --------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ FINAL INSPECTION BY:.,-.� �� :.---------- Date------- = /, --------------------------------- rSANOAQUIN LOCAL HEALTH DISTRICT 1601 E.Hazollon Ave, 300 We st'Oak Street a ` x.124 Sycamore Street 205 West 9th Street k Stockton,California Lodi,California Manteca,Califordia Tracy,California F.P.0 Q.