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rVK Ut-HLt USt. --------------------------------------------------------- -------------------------------- ---------------- APPLICATION F6R-SANITATION PERMIT Permit No. .a2pQ- T ------------------------------------- ------ ----------- (Complete in Duplicate) This Permit Expires 1 Year From Date Issued Date Issued Application is hereby made to the San Joaquin LocaI Health Distract for a permit to construct and install the work herein described. This application is made in compliance with County Ordinance No. 549. y JOB ADDRESS ALLOCATION-----------. Owner's Name ------ yn .�/5.e- ----------------- --- ------------------ ------------------ Phone------------------------------------ Address,_.-------- ��--------- ContractorsName --------------•--------------------------------------------------------------------------- ------- ------ Phone................................... Installation will serve: Residence Ef Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: _e----- Number of bedrooms _1---- Number of baths I---- Lot size ------------------------------------------------__-___----_ Water Supply: Public system ❑ Community system ❑ Private ❑ Depth to Water Table -70, ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam �j Clay Loam ❑ Clay ❑ Adobe ❑ Hardpan ❑ Previous Application Made: (If yes,date.--_------------ -) No ❑ New Construction: Yes ❑ No ❑ FHA/VA: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: _ (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tank: Distance from nearest well__O�-------Dista�cc�i from foundation_AP�-_-.----.Material---61�Y�2f.Gc No. of compartments----. --.. __[__�",r.___Liquid depth_---.-.�................Capacity.�_------------------ e Disposal Field: Distance from near st wellt�r;?.--------_Distance from foundation....�.�-.--._-...Distance to nearest lot line---4----------- [t Number of lines___-- ..---- -------Length of each line-lOp_-Y' ___'_'0_.Width of trench- -- Type of filter materia-- ---------------Depth of filter material_4f0-.!`.._..-------Total length-A Q----_--__-----------------_-. Seepage Pit: Distance to nearest well----------------------Distance from foundation--------------------Distance to nearest lot line----------------- Ow ❑ Number of pits----------------------Lining material------------------.----Size: Diameter--.-------------------. Depth----------------------------- Cesspool: Distance from nearest well-----------------Distance from foundation.------------------ Lining material.........---.-..-----------.--------- El Size: Diameter-------------------- -----Depfh----------------------------------------------------Liquid Capacity----------------------------gals. Privy: Distance from nearest well-------------------------------------------------Distance from nearest building----------------._-----------____.______- ❑ Distance to nearest lot line--------------------- -r--------------- Remodelingand/or repairing (descri4�e):--------- ------ -----------------------------------•-•-•----------------------------------------------------------------------------------------------- ---------------------------------------------------------------------------------------------------------------------------------------------•------------------------------------------------------------- ------------------ ------------------------------------------------------------------------------------------------------------------ ----------------------------------------------------------------------•------------------------------------ --- --------- - ---------- --------------------------------------------------------•------------------------------------------------------------------------------------------------------------------------------- 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 n regulations of the San Joaquin Local Health Disfrict. (Signed) -----f- 44--------- ------------------------------------ ------------------------------------------(Owner and/or Contractor) By:----------------------_ �-------------1----------------------- ------------------------------------------------------ -- -----(Title) -------------------- ----------- ---- --- (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). 10 FOR DEPARTMENT USE ONLY ----------- --------------------------------- - DATE... APPLICATION ACCEPTED BY.... --- ---...... ..... . . - REVIEWEDBY----- -------------------------------------- --------------------------------------------- --------------------------------- DATE-------------- BUILDINGPERMIT ISSUED------------------------------------------------------------------------------------- ---------------- DATE--------------------------------------------------- Alterations and/or recommendations--------------- ------ ------------------------------------------ -------------------------------------------------•------------------------- -- -------------- ------------- ------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ 1---------------- ------------------ - -- •---------------- ---------------------------------- ------------------------------------------------------------------•----------------------------------------------------------------------------------------------- --------------------------------- -- ---- --- ----------------------------------------------- --- ------ --- ------------------------------------------------------------ ------------- -------------------------------------- FINAL INSPECTION BY: ---- - Date--/-,P-4c...--------- SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Hasellon Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,California Manteca,California Tracy,California F.RCC.