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USE411- 01-40-1 O FILE ' APPLICATION FOR SANITATION PERMIT Permit No:"v .: .3., - -------- --------------------------------------------- (Complete in Duplicate) - This Permit Expires 1 Year From Date Issued 4�` ' Date Issued Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work In described. This application is made in compliance with County Ordinance o. 549 �}f * 1 JOB ADDRESS AND LOCATIO.A, ? _J/ ��J -----�` � �� ..----•---- ---------------------------------------------•-- R. .� Owner's Name �: - -----------------•-•------ ----------- : ------------- Phone t � _� Address---------------'-------- � 1 ` --- ------------••------•----- leg { Contractor's N_amey.. : ------------ Phone-----------------------•--•-------- Installation will serve: Residence g o'Apartment House ❑ Commercial ❑ Trailer Court [] Motel ❑. Other ❑ Number of living units: ,J--_ Number of bedrooms,-g.- Number of baths _ .-_ Lot size IA.115P_______________________ 4 Water Supply: Public system ®Community system ❑ Private ❑ Depth to Water Table 2ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel L]/Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe 2--Hardpan ❑ Previous Application Made: (If yes,date--------------------} No R20"_New Construction: Yes �No ❑ FHA/VA: Yes 8— No ❑ F TYPE OF INSTALLATION AND SPECIFICATIONS:,. . 1 (No septic tank or cesspool permitted if public'sewer is available within 200 feet.) Septic Tank: Distance frora� nearest well__ ___=___:___ "Distance f om foundation____. __. --_<____Ma,ter�saL__ C _ __.. �. 3 c P �- 5''�- �` ._..Liquid depth == Capac,tY ` No. of compartments + __-__Size_ ___ ��----- Dis osal Field: Distance from nearest well-_-_ _._.Distance from faiandation__� �______Distance to nearest lot line___ p®� Number of lines------- ----------- f� ~ t .__ ;__._Length of each line..��___.<-__F� - - Width of french---._-1�_._..._.,�_-________________ Type of filter material_/,e- -Depth of filter material__Ze___ ___-Total len''gth-._,1 __ _________________-__._ Seepage Pit: Distance to nearest well-�. '______Distance fr m-f ation___� __/---. y V DDis ante to nearest lot line______.._.___._ �� Number of pits---._ -_-..------Lining material-4 ,��- ize: Diameter-J. }--- ---------- Cesspool: Distance from nearest well_________________Distance rbrn foundation._.____-__-______.Lining material---.----_--__-__________.____________. ❑ Size: Diameter--------=-----------------------------Depth------- ------------------------.-- ----------------Liquid Capacity-----------------------=----gals. Privy:" Distance from nearest well_____ ___________________________________________Distance from nearest building------------------------------------------- El ____-_-______-_-_.--.-.---_---_--____._.❑ Distance to nearest1ot line---- --- --------------------------------------------------------- t -__.--_---_------------------------------------------ - --------- . .._ .. F A Remodelin and/or repairing (describe): r 9 P 9 I � '� --------•--•--------•--------•-•---------------------- ----•-------------•--•------------=--------------- -------•--•--------•---------•--•----•-=-----•---•----••---------------•--------•------•------------------------ -------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------•------------------------ 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)------------ ------------- (mer-andfor Contractor) i -- Title _ � � -- SY ( } �� 1 - (Plot plan, showing size of lot, location of system in r ion to wells, buildings, etc., can be placed an reverse side). 'POR DEPARTMENT USE ONLY ;. APPLICATION ACCEPTED BY___ om---- --------------- REVIEWEDBY----------------------------------_---...----------------•-----------------------------------------•-••-------.._....-- -•- DATE----------------------------------- BUILDINGPERMIT ISSUED------------------------------------------------------------- ------ ----------------- DATE--------------------------------------------------------- Alterations and/or recommendations:._/_aJ`__ . .- /�-- - -- r��s-r ------8- --- f-- _ --------------- n FINAL INSPECTION Bz �� Date r------_ . f 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 t,rj ,Tracy California r � E5-9 REVIsEC 6.59 F.P.CC.ZM 6.60 - r ��