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FO,3`1ROFFICE USE: �> ff A 1 3� __%------_--------- --- !oo------------- APPL1CATiON AOR SANITATION PERMIT Permit No. ....� - ---------------------------- --- ----- --------------- (Complete in Duplicate) 3 Ia S✓ This Permit Expires 1 Year From Date Issued Date Issued _____ �1�_____ ____ Application is hereby made to the San Joaquin Local Health D4frict for a permit to construct and install the work herein described. This application is made in compliance wACgun_y in N 4 . f JOB ADDRESS AND LOCATION. -�� _t- .__ ,_ T� � '� GG fI� �V /' Olt._...0 JL Owner's Name----- rf-------.- ''`J Address----------- --...... ....... �6_ ----Tg---------- -------- -------------------------------•-- Contractor's Name--------' lfc ' `sf/------------------------ --------------------------------------------------------------- Phone--7. ------ Installation will serve: Residence Apartment House ❑ Commercial [❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: _1---- Number of bedrooms _J__._ Number of baths __L__ Lot size ------$e .Z_---X_/-50____________________ Water Supply: ,Public system ❑ Community system-E] Private ©" Depth to Water Table ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay [] Adobe a- Hardpan ❑ Previous Application Made: (If yes,date....................) No E� New Construction: Yes 21 No ❑ FHA/VA: Yes [may No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) p Septic Tank: Distance from nearest well__s7°.__r_.-_Distanc6 from foundation----/_o---------Material_0___'7 _ _7-_uI'J4-` Q� No. of compartments--------Z------------- Liquid depth------y' ---- --------- Capacity__lQ_" - f Disposal Field: Distance from nearest well_S6'..___Distance from foundation----/.°----------Distance to nearest lot line---3___ 0___ Number of lines____________L-._.---_-----------Length of each line-------- _____________-Width of trench-------Z.......__---_---__-_____ T e of filter material______ .____:._ --Depth of filter material____/-__-- S'(,(lfiJ P Yp /Qoc/ p J r Total length y t: Distance to nearest well _�� ___Distance from foundation-----/-')-------- to nearest 1 3_ ___. f [G�c Number of pits-------2 ---------- ing material------e°'-_&.Size: Diameter._._ `__f..........Depth_. .._/.. ______________ � Cesspool- Distance from nearest-well-------------t..-Distance from foundation------------------_Lining material------------------------------------- 00 ❑ Size: Diameter----- ------------------------------Depth------------------------------- --------------------Liquid Capacity- -------------------------gals. Privy: I Distance from nearest well-------------------------------------------- ----Distance from nearest building--------------------------------------- -. ❑. ~� Di 3tartee•-to_nearest lot line------ -- -------- ------ ----------- ---- ---------------------------- ------- ----------------------- Remodeling and/or repairing (describe):-- ----- ""`.=-�---- . r ——�_ --------------------------------------------------------------------------------------------------------------------------------------------- ------- '-' a ------------------ ----------------------- ------------------------ -_----- ------------------------•----------------------------------------------------------------------------------------------------------------------------•------------------ 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 ofthe an Joaquin Local Health District. (Signed)-------- ------ - --- ---- - ' ._ -- r.--- c--.------- -----_-._.(Owner and/or Contractor) BY: 4 - -------------(Title)--------------------------------------- -- - ----- (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY ! ZREVIAPPLICATION ACCEPTED BY-----e-------- --------------------------------------------- DATE----- Z---- -------------------------------------- REVIEWED EWED BY---------------------------------=- ------ ---- -- ------------------------------------------------------------------- DATE BUILDING PERMIT ISSUED----------------- -------------------- ------ ---------------------------------------- DATE------------------------------------------------------------- Alterations and/or recommendations:-----�tz�.�- ........... �--------------------------'-'--------------------- ------------- ------------------------------------- -------- ----'------------- ---- --------------------------------------------------------------------------------------------------------------------------•--••- ------------------- --------------- ------------ --------------------------------------------- -- ----'-------------------------------------------------------- ------------------------------------------------------------- --------------- ------ -------------------------- 10 FINAL INSPECTION -" - --'- -- -- - /� Date----- - SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Haselton Ave. 300 West Oak Street 124 Sycamore Street 205 West 91h Street Stockton,Callfornla Lodi,California Manteca,California Tracy, California r.R.c o.