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OFFICE USE - •` GJ xY Permit No. { --- APPLICATION FOR SANITATION PERMIT (Complete in Duplicate) Date Issued __------------------------------- - --- -�-- This Permit Ex ices 1 Year From Date Issued Application is hereby made to the Sari 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. lC l4 - JOB ADDRESS AND LOCATIO274i Q �- � l- �f 'Owner's Name 1Q - 1---- fes`- ----- --------------------------- Phone. = Address �/r ----------------------------- -----------/ ll ------------------------------ -••---------- Contractor's Name--- -- -- -- -��-�--'Q- ---- - -------•-.- Phone------------------------•---------- ---- --- Installation will serve: Residence �partment House ❑ Commercial ❑ Trailer Cour} ❑ Motel ❑ Othe�� ` 1 �s s' � ---- ----------------- Number of living units: -----{.- Number of bedrooms - _- Number of baths Lot size -- .--- th to Water Table-y ft. Q Water Supply: Public system ❑ Community system ❑ Private [��P Cla Loam Clay Adobe ardpan U Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Y ❑ y ❑ No Previous Application Made: (If yes,date----------- No [L]�NeQ�ru Yes ❑ No [/FHA/VA: Yes ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: l (No septic tank or cesspool permitted if public sewer is available within 200 feet.) r %---_-Distance from foundation---d/_r-------Material_.'.C-e_141,----G--�---- t-mss Septic T Distande--from nearest well-- --- Size____Z j�� Liquid depth----_21/-----------Capacity f No. of compartments------- l iI / ' Q-Z--.--Distance to nearest lot line-- �---- Disp^osa�l i i Distance from nearest well..S .-_-.-Distance from foundation.-/.-}-- -� L� I n fh,of each line--_�j� / -------Width of trench....-- ---------- Number of lines-----_� /--, � g r � Ge th of filter matenaL---./ 2_-_Total len th--. 1 j g -�--•----- - Type of filter material_--,1,�3--- _-- p I �- -= r Seepage Distance to nearest well. �-.----------Distance,f"r�m {o inflation ---- o=f-Distance t-- nearest lot i"-_ �� /�_ Size: Diameter ��J----- DepthC -- �' Number of pits-- Lining material _--� _ -- Cesspool: Distance from nearest well-------------- --Distance from foundation----_-.---_---.....Lining material--------.------- __----- I -Li uid Capacity gals• I Size: Diameter-- ------------------------ --------- Depth------------------------------------- ---------- q p Y- --------- -------------- I ❑ _----_-.-Distance from nearest building------------------------------ -------- - Privy: Distance from nearest well_---------_------------ -- - •----------------------------------------- - ------------------------- Distance to nearest lot line------------------- -------------------fir raj h R ---- - -------------------- e -------- ------- I e + d�eling an ------------------------------------- --------------------- i �- - ------ --- rre aJ ---- --------- -- • -- --- -- - ------------- -- ---- -- :------------- ------------------------------------ ------------- ------ I hereby certify that I have prep this application and that the work will be done in accordance with San Joaquin County ordinances, State a s, d rules end a ns of the San}Joaquin Local Health District. t - -- ---_(O(Owner an Contractor) -��------ _ - - --- ---- w and/or C or) ------- (Signed)--------- -------- ------ 1 ---------------- ------------------------------------ -- - - (Title)-- By:------ ------------- ----- buildings, etc., can be placed °n reverse side). (Plot plan, showing size of4lot tion of system to wells, FOR DEPARTMENT USE ONLY SY-- --�- - - DATE-- '_�'--ate--a&S---------------------------------- APPLkCATION ACCEPTED I DATE--------I -------------•-------------=------- ---------- - REVIEWED BY--------------------------------- ----------- ------- ---------I----------------------------------------- DATE--------`----------------------=------------------- BUILDINGPERMIT ISSUED----------------------------------- --------- -------------------------- Alterations - ------------------Alterations and/or recommendations:--.Q-.3.-'-104V+ 1 ------I 1%S.Pe4ik&i ----------------- - ----------------------- - = -------------------- ------------ ------------------ -------------------------- ----------- , I ------------ ----= F--------- ---------------------------'-------------------- --------------- t ---------- - ----- ------------------------------ ------ t l � Date-------- `-�_'. '��''----- - -- ----- ----- ---------"--•---=.J FINAL INSPECTION BY--------------4--- -.- - --- ---- ----- ' SAN JOAQUIN LOCAL HEALTH VDISTRlCT r205 West 9th Street � � 300 West Oak Street 124 Sycamore Street 1601 E.Hasslton Ave. '" California Lodi,California Manteca,California' Tracy, Stockton,California a r � k l