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FUR UFFK lz USt: ...................... ...............--_ ------ APPLICATION FOR SANITATION PERMIT Permit No. _-- -............. .. (Complete in Duplicate) 0 ` Date Issued .. ......... ------------------------ This Permit Expires 1 Year From Date Issued _ ..............._......_.......__.... 1 . 017- Application is hereby made to the Sen Joaquin Local Health District for a permit to constr nd insta ork herein described. This application.is made in compliance with County Ordinance No. 549. -J ADD. S ' �rf�w a / /gypp y� JOB ADDRESS-AND LOCATIO5: .. ... . 4.d.. --.200- ._ .r1..1. - --- ...... ...Owner's Neme. -- - _2... !. .... _........... ....... Phone - --..............-- Add Contractor's ----------------------- ....................................................___................................ Phone-----..................- Installation will serve: Residence, Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel [❑ Other 0 Number of living units: .1..... Number of bedrooms P---. Number of baths ../---- Lot size --..��a .....�... Fd" �'..:..... Water Supply: Public system ❑ Community system ❑ Private X Depth to Water Table ba.- ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam O� Clay Loam ❑ Clay ❑ Adobe❑ Hardpan ❑ Previous Application Made: (If yes,dote...._ ------- ----) No New Construction: Yes_M No ❑ FHA/VA: Yes ❑ No ❑ TYPE-OFINSTALLATIONAND SPECIFICATIONS: �, ..= (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Q -`-_ � y Septic Tank: Distance from nearest well-.. .....Distanc 4,fro foundation...!!?!.......Me rial...f�1!T'!��r4.....I............ . No. of compartments.....................Size- .!ttr......Liquid depth.... ..............Capacity./AXAV....... I ' Disposal Field: Distance from nearest well..)a...._.Distance from foundation.ld�.-........Distance to nearest lot line-.tS......... i Number of lines�...'�.. -...__._ .-_-.. Length of each line-- 4F-0-. _.-_--- Width of trench._,x__e/..*.................... Type of filter meteriej`LI:4!!. Depth of filtermaterial.-- Q--�.---------Tote) length..-1.4..f1.. ....................... Seepage Pit: Distance to nearest well/ Distance from foundation--------------------Distance to nearest lot line....------------- ❑ Number of pits.:...................Lining material.................:'_Size:.Diameter-----------------------Depth............................... .. Cesspool: Distance from nearest well.................Distance from foundation-:;.. _..Lining material...--............................---. 1 El Size: Diameter.....................................Depth.--.............. -------------I-----------Liquid Capacity gals. l I s ''1 - ..Distance from nearest building Privy: Distance from nearest well..............::...................._�- g------------------------------------------ Distance -- O ❑ Distance to nearest lot fine---........... L'^..-' ) .. ` .......V.................................. ...:..._............._.............----------------------------......_.. Remodelingend/or repairing (describe):..................... •......................................... ...............................................---._- ......--.................... ----------- _ -- -- _ - - ----------------- - -'------- ------------------ -- ----- •- ------ -------------- ............................--- ------........................... 1 1 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 end regulations of the San Joaquin Local Health District. l o \ I (Signed).....:M -- -- ------------- ---------rte: --------------------------- ...... and/or Contractor) By:....................c.::...........----.:..:-- -- . --- - . -- ......._....----------.--:.:-_:.(TI#lej.......................I.................._._.._............... (Plot plan, showing size of lot, location of system in relation to wells, buildings, eta, can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY... . . REVIEWEDBY--------------------------...................................... ------------ -.-......................................... DATE.................... .... ....-....--....... - -- BUILDINGPERMIT ISSUED---- ----'---------------------------....----....-------•---------------------------------- DATE............................................................. Alterationsand/or recommendations...................................................-.......•.................................................................................................... A ............. .... -`-----------............. ............._........._......_.......... ................. ........-.....-------------------------------------------- . _.-....-...........--...............------------.. T i . FINAL INSPECTION BY:. ... 2ttr - ------------------- Date...... - ------------ -------- ,l SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Stint 300 West Oak Street 124 Sycamore Street 205 Wert 911,Street Stockton,California Lodi,California Manteca,California Tracy,California • E6 9 REVISED 6-09 014 a-at ATLAS