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------------------ �r APPLICATION FOR SANITATION PERMIT Permit No. --- �--- ---- -- - ----- ----- ---- --- ------ ---I � This (Complete.in Cjuplicate) s permit Ex ires 1 Year From Date Issued "' Application is hereby made to the San Joaquin Local Health District for a permit to construct and install}hatIssu�� Q2L �,� ozThis application is made in..complian}ce with County Ordinance No. 549, Z i AX. �(I r {- La's Y! 'Y( r a work herein described. JOB ADDRESS AND/L -CATION,�_41(LOwner's Name------ /` e!7 i- _. _ /` - --- ---------- - I' ------------- ----------------- _-_�_------� Z -- ------- one"- ---------------------•--•----- Contractor's Na " „� +. ------------------------------------------------------ me Installation will serve: Residence ---" ` -------- - - ---------•--•--- ------ Phone----•--•---•----------------------- El_ Apartment House i Number of livin units: "" ---." ❑ Commercial ❑ Trailer � Motel 9 Number of bedrooms _� ❑ Other ❑ Wafer Supply: ,�. Number of baths ---I... Lot size , pp y: Public system ❑ Community system � ❑ Private ------------ -------•------- Character of soil to a depth of 3 feet: Sand Depth to Water Table -" �{t � ❑ Gravel ❑ Sandy Loam ❑ Clay Loam � Cla Previous Application Made: (if yes,date__________ ____ _') Y ElAdobe E] Hardpan 1�;No ❑ New'Construction: Yes ❑ No ElFHA/VA: Yes ElNo ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: .r te{No-septic.fank_or-ctsspool_permittedrif,-public.sewer-i available:wifhin 200-fest:} Septic Tank: Distance from nearest well- "t('Q_-__ Distance from foundationt? No. of compartments_---_ ___f- Material-- z €€ Liquid depth---------— ------- Disposal Field: Distance from nearest well-_S, -1,. Distance from foundation" Capacity.-�-B"t7 Number of lines___-f"-""-_ ----Z9 to nearest lot line___3_""I-_-_ ----------------Length of each"line-__ . Type of filter maferial_�= r � -"-- f� Width of french.--- �,b Depth of filter material____,[- __-___ _ ._Total len length J __ ------------------- Number ____"____ ------ Sege Pit: Distance to nearest well__ ,404----------Distance from foundation- g Number of pits------ y� .-----.Distance to nearest lof fin "- l' �- --_--_-Lining material----JO SW-4-----Size: Diamefer---.—I1__'-_ Cesspool: Distance from nearest well '-"- -.-__ istance from foundation_..__._--_-- ""----- Depth_._- --- - 11 ❑ Size: Diameter------ ------- " ---.._« -.Lining material_ --_----- Priv e� ------------•------------------- ----- --- ------Liquid Capacity-.---- --------gals. 1 Y Distance from nea�esf well-------------- --- --------- It Distance from nearest building............................... -- -- -- --- -- --------- 'f1 El Distance to nearest lot line__ : L - ------------------- ----------------------- ----------------- ------- Remodeling and/or repairing (describe):_"_______________ _____ ----"""- ------ - - -------- ------------•------------- -------------- ------------------- ---- ----- ------ ----- - rn ' ----- - ---------------------------------------------------•-------- ------------------------ ----------------------------------- -------- ! hereby`certify that I have prepared this applicafion and that the work will be done in accordance with ordinance5.'State laws, �d rules and regulations of the San Joaquin Local Health District. San Joaquin County D (Signed)--� - 3 ---------------- -- -�� ----- ---- C ----------_-----_------�`�--�"`---�� caner and/or ontract -(O nd/o or) ----------------- - -----(Title)--R_ (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 APPLICATION ACCEPTED BY__ _ E �e..ccr ---------------------------- --------- p REVIEWED SY.- DATE_ 1-- a�- BUILDING PERMIT ISSUED----------------------------- ------------------------------------------------ ----- --- ---------- ------- ------ DATE----- ------ ----------- � -------------------- ----- ------ DATE------------------- - ------------------------ terations and/or recommendations:--___ .._._..._--"_--_ - --------------------------- ----------------------------------------- -------------------------------- I----------------- -- ------------- --------- ----------------------------------------------- ----------- --------------- s --------------------- ------ ----------------------- ----------------------- ----------------------------- FINAL INSPECTION BY. ` ----- - Date---------- ----- - - - --------------------------- _____ SAN JOAQUIN LOCAL HEALTH DISTRICT 1661 E.Ha:etMon Ave. 3op?Wg rs Oak Street I � Stockton,California � 24 Sycamore Street di, California[alifornia � 205 West 9th Street Manteca,California Tracy,California