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FOR OFFICE USE: ' --------------------------------------------------------- APPLfCATIOPIi"FORSANITATION PERMIT Permit No. 2– ------ -- -------- -- ----------------------------------- (Complete in Duplicate) ------ r------- --- 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 install the work herein described. This application is made in compliance with County Ordinance No. 549. JOB ADDRESS AND LOCATION----------6[d&VT)1.1V6------ --------------------------------------------••- Owner's Name--------------- ------ ---p---------•---------------------------------- ------------------------------------------- Phone-03 _4�6-7----•--- Addressl�4 �_.=1 iG.---•--•--------------------------------------------- ------------------------------------------------------------------------•- Contractor's Name -------------------� ----------------------•-------••-------------------------•-------- -... -...---••------ • •---------.-- Phone---------------------------------- � Installation will serve: Residence [Apartment House ❑ Commercial ❑ Trailer Court 0 Motel ❑ Other ❑ Y ❑ Y Y ❑ � baths �--- Lot size -------/�T------------------------------------------- Water -------• - -•- •----------- Water Supply: Publics stem Community system Private D Number of living units: __ ____ Number of bedrooms -3__._ Number of epth to Water Table -------- {t. Character of soil to a depth of 3 feet: Sand [] Gravel ❑ Sandy Loam ❑ Clay Loam [j Clay Adobe [] Hardpan ❑ Previous Application Made: (If yes,datejc '. 6 .___1 No ❑ New Construction: Yes 2"No ❑ FHA/VA: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: � - '(No-septic-tank or.-cesspool.permitted,if.public sewer is available within 200 fept.) Septic nk: Distance from nearest well---6.0.----__Distance from foundation__.Disposal Field: Distance from nearest well.__�o0_____._Distance from foundation___1P_ --------Ma erial___C49-_____----------- ------ No. of compartments_...._a 2_ '/ X6_______________Size__ ----------Liquid depth--� ----- ------Capacity--�9�b-------- Dis p A4?---------Distance to nearest lot line___��___-.______ Number of lines-- ----__ g W---------------Width of french.._.�GI��------------------ [� �____________________Length of each line________ __- Type of filter -- ---------Depth of filter material------l�7---------Total length__---,910------------------------ Seepage Pit: Distance to nearest well-------------------_--Distance from foundation-------------------.Distance to nearest lot line----- ------------ ❑ Number of pits---5 ---------------Lining material--------.--------------Size: Diameter---------------------- Depth_..-..______..___________------ � Cesspool: Distance from nearest well-----------------Distance from foundation-----.----------------Lining material---_--------------------------- .__._ ❑._ Size: Diameter ---,Depth-- --------------------------------------------- q ------------ ----------- Liquid Capacity.......---------------------gals. . Privy: Distance from nearest well--------------------------------------------_----Distance from nearest building------------------------------............ ❑ Distance to nearest lot line =_ ------- - ---------------- ------ -------------------------------------------------------------------- r Remodelingand/or repairing (describe)--- ------ ------------ ----------------------------------------------------•---------------------------------------------------------------------------- ----------•----------------•-.--------------------------------- ----------------------------------------------•---------------------------------------------------------- --------------------------------------- r -------------------------------------------------------------- -----------------------------------------------------------------------------•-------------------------------------------------------- - -- - -------------- - . 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. _r =W: �(„S"i.`gn"e:d'B)Y� f � ` {Title)---------------(=Owner and/or Contractor)rr ac-tor:) - -- -' `- - T----- - ---- : - /-`" _ Y- - -- ------ .-------- -- - ------ --------------------- --------------- (Plot pie howing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). FOR PARTMENT USE ONLY APPLICATION ACCEPTED B17 Y ___ ___________ DATE____ - --_ - -------------------------------- REVIEWEDBY----------------------- ---------- ---------------------------------------------------__------------------------ DATE-------- - BUILDING PERMIT ISSUED---------------------------------------------------------------------------------- ------------------ DA•TE------------------------- -- --- - -- - - ------------------- Alterations and/or recommendations---------------- ----------------------- --------------------------------------------------------------------------------------------------------------------- -----------------------------------•----------------•------------------ --------------- --------------------------•----------------- ------------------------------ ----------•------- ---- --------------------------- I FINAL INSPECTION bate--------------------------- - ---- ----- -- f I AN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Haxelton Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California Lodi, California Manteca, California Tracy,California F.P.CC.