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.�1F0 OFFICE USE: Y —'r` .. r: � A --k -------------------------------------------------------- APPLICATION FOR SANITATIONPER IT Permit No. ...... ..............-- (Complete in Duplicate) • .� Date Issued --_ --------------------,----------------------------_�-___ 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�lOrdinance No. 549. JOB ADDRESS AND LOCATION--- .. f r -----------vz Owner's Name_.. ; l -- ---------- -- '`• Phone.__.....__. -------------------- -••--•• -------------- -••- -- _ - ------------------------------------------ Address..... 4"Contractor's Name---- ---- -• --�-.----•-------------------------------------•-- --------------------. -'----------------.-- Phone----•-----••----------------------- Installation will serve: ;Residence Apartment House [❑ Commercial F] Trailer Court ❑ Motel ❑ Other ❑ Number of livin1. g units: _,�____ Number of bedrooms __�_. Number of baths ._/_. Lot sizeN�O. .!�J_ _________________________________ f Water Supply: Publics stem �ommunity system PP Y• Y y y ❑ Private ❑ Depth to Water Table _��ft- . Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam [] Clay Loam E] Clay ❑ Adobe Zk-Flardpan ❑ Previous Application Made: (If yes,date------_--------------) No ®-'New Construction: Yes ❑ No 2?. `0FHA/VA: Yes ❑ No ®-� TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Se tic rank: Distance from nearest well_________________Distance from foundation_____________..---.Material___________-.^_______.___-_-______-_- No. of compartments------ ------Size-----••----------------••-------Liquid depth-------- ------- ------Capacity----------------.-D is ._... ' 7oral F' Id: Distance from nearest well________________Distance from foundation___ -------Distance to nearest lot line_-----_r___..___ W...0or Number of lines----------- -- --------------Length of each line----__.99 e ------------Width of trench--�� .-�----•---------------f- Type ,/per,, ,0,.e-Depth of filter material___ .-.--Total length___.__..-_s T e of filter material -._ \ Seepage Pit: Distance to nearest well--------""'--------Distance frixn fou dation___....-.,Distance to nearest lot line---- .-�._ p' /_-_________-Linin material___ - jd�rSixe: Diameter_ r Number of its----f -- g - �+..��'-----.Depth_..,��-�-�--•----------• x.11 Cesspool: Distance from nearest well-----------------Distance from foundation___-----------------Lining material-------------------------------------- El Size: Diameter----- -------------------------------Depth---•------------------------- ----------------------Liquid Capacity----------------------------gals. i Privy: Distance from nearest well-------------------------------------------------Distance from nearest building------_-___________--___________-..___._. ❑ Distance to nearest lot line.----------- ----------------------•----------------- }} T Remodeling and/or repairing (clescri[ti:--------- •-----•-------•---------------------------•-•---------_--•----_ -----------------------------• ------------------------------------------------------------------------------------------------ ----------------•-------------------------•---------••-------- ••--------------- I ------------------------------------------------------------- -----------------------------------------------••-------------••---•--------------------•-------------------------------•------------•------------------------ 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 rules and'r gulations of he San Joaquin Local Health District. (Signed)-------------------------------------- ---- -------- ----------- --- -- -------- -- - r Contractor 1. ) By: --------------------•--•----:--:---------------------------- ---`-----------_(Title)-- - 12ner-�/ - '.---- -- - ----------------- ° (Plot plan, showing size of lot, location of system in rel ' n toells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY---- -F 13-0---------------------------- ---------------------------------------- DATE----- REVIEWEDBY------------------------------------------------------------------------------------------------ •---------------------------- DATE----------------•--- BUILDING PERMIT ISSUED-------------------------------------------------------•-•-------•------ ------ DATE. Alterations and/or recommendations:--------------------------------- =--------------------•------------------ ------------------•-•--------•- -----•-------------------------------------- ------------------------=------------- -- ---- -- -- ----------•--------------- -- 2L � ------ --------- i ._ .. --------------------_------- _ ____ ____ ________ _ -----------------------.-____________-_____.h_______-----____.._____.____.___.____..___.____--_-_______--•-.____ FINAL WSPECTi BY:- Date---------------------- _`401.. SAN JOAQEIIN LOCAL- HEALTH DISTRICT-, 130 South American Street 300 Well Oak Street ♦ ` k z • 124 S ca ore Street YOS West 9th Street -, y Stockton,California Lodi,California Manteca,California Tracy,California K6.9 REVIBEO 6.79 F.P.00.2M 6-60