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FOR OFFICE,USE: � 4 ............ ------- `APPLICATION FOR SANITATION PERMIT Permit No. .. .-. . ------ ------------------------------------------- (Complete in Duplicate) I tt I/ - � ........ .... --------------------------------------------------------------________________--------------------------------------------------------------��__ This Permit Expires 1 Year From Date Issued Date Issued ... . ..... Apiilication is hereby made to the Sart 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. q .........................•-------•---------•---...........---•-•------.-_... JOB ADDRESS AN --------��5. .�--------------� -•------------------------------ Owner's Name.. ----!Q1.C,4,TI0 . --•-- --------•------- Phone. Address................ ----••-----•-•-•- ----••... ------•--------- Contractor's Name--------------------------------------- --------------`.----------------------------------------------------------------------------------- Phone----------------------------------- Installation will serve: Residence Apartment House ❑. Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units. -�-____ Number of bedrooms ___�-. Number of baths _1---- Lot size ------ _______ ______�...... ......_____._ Water Supply: Public system�Community system F1 Private E] Depth to Water Table�1 ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ A&64 Hardpan ❑ Previous Application Made: (If yes,date_..................)- No7�—New Construction: Yes ❑ No;2�1 FHA/VA: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Material_--__�-�_ ��— Septic Tank: Distance from nearest well-_ � -__Distance from foundation__f____Q__________ _ ' .-_._Sixe_�47f�_ __ _ _.Liquid depth__ d'_'!________Capacity..- Qr.?_.___ No. of compartments.._"________ F Disposal Field: Distance from nearest well. l „_ Dis om foundation./_!f_ .... Distance to nearest lot line... Number of lines____________ ___ ____ _____ ____Length of each line... _ __ 0 1� Width of trench____.Z.Z/..�!_____ Type of filter material. ,. \.__Depth of filter material-----I.(r--__......Total length----- ___ ..... Seepage Pit: Distance to nearest well__ 1ir.,e�____..Distance from foundation- _''.....Distance to nearest lot line......_.....".... Number of pits------t-------------Lining material.-P_o�'-i-------Size: Diameter_�_3 4r`_.......Depth------.2-.'d'.-°--:_--.--- s Cesspool: Distance from nearest well-___•-_-_._-_---Distance from foundation--------------..___.Lining material.................__..._......._...... ❑ Size: Diameter.--• _ Depth--------------------- - -----------------------------Liquid Capacity-------_------------------ f l Privy: Distance from nearest well-------------------------------------------------Distance from nearest building------------------_-.......__._-..---_.-. I ❑ Distance'to nearest lot line----- ------ ---------------------- ------------------------------------•---------------------------------------•-----•----------------------- Remodeling and/or repairing (describe):----- - 4 -----•----•-------------•-----•--•---•----------•------------- .—. ----- -----------------------•--•------ -------••---------••--------------------------------•----------•------------------------------------------------------------------...--•------•-------------------------•-- 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 regulations of the San Joaquin Local Health District. (Signed)__ ----------------------------------------------------------- -_,(0wWffiaWW*1M=Contractor) By:-•--..................................................:- ----- > ------------(Title).......... --------------------------.-..----- ----------------- (Plot plan, showing size of lot, location of system in relation t wells, butc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY---- , - - ==�`--------•--•---------------•----------------:DATE_/�-- -_�- 1_1--------------------- REVIEWED BY------ ----------------------------------y --------------------------------------------------•-•-•------------------- DATE........................................................... BUILDINGPERMIT ISSUED--------------------------------------------------------------–------------------------...----•-•---- DATE------------------------------------------------------------- Alterations and/or recomnien ations-------------- --- -- .... ------•- - ---------------------------------:.- -•--•------•---..... ----------------------------------------------------------------------------- -------- --------------------------------------------------------------------------------------------------------------------------------------- ...........-� --------------- -----------------------------------------------------------------------------------------------..-.----------------------------------------....---------------------------------------- FINAL INSPECTION BY:.--C/...4 ------ Date J----------------------------------•--- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,California Manteca,California Tracy,California Ei;.9 arvls Eo 9.99 2M 6-6t ATLAS l:'-