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I-VKU FIC-.E USE: r ,� APPLICATION FOR SANITATION PERMIT Permit No. .-41f ---- ------- ----I-------------------------------- --- ----- (Complete in Duplicate) ------------------- 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__WzV_/,7 C-_- ,rye-------- 1"u•€cn 1 Owner's Name-.......... qls/TC��1C1!?---.lv��!'/�_i�.�--------------- -- - ----- --------------- ------- -------•---- Phone-- - . ..._ _ s r_A�' Address------------------_-143r----------•-- ..h_/-r --- Contractor's Name-- s�Q% .A �'=-------------------------------------------•----------------------. Phone_17T_/.�0 I Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ I Number of living units: -_/___ Number of bedrooms _3__ Number of baths ---f--- Lot size ---- 9fe"- w"__________________________ Water Supply: Public system ❑ Community system ❑ Private Depth to Water Table 40--_ ft. k Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam Pfl Clay ❑ Adobe❑ Hardpan ❑ ° Previous Application Made: (If yes,date--------------------) No Ik New Construction: Yes ❑ No IM FHA/VA: Yes ❑ No ,g r 1 TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permifted if public sewer is available within 240 feet.) 1 Septic Tank: Distance from nearest well------------ Distance from foundation------------ Material_________________________________________..:.._. I ❑ No. of compartments------ --------------Size--------------------------------Liquid depth----------------- : :.. Capacity----------------------- * Disposal Fielyl:f Distance from n' _40 .Distance from foundation____ o_�____.Distance to nearest lot line_-eP_ R te` Number of lin es_________%-=-----------------Length of each line__-___`Z'--_ _____.___.Width of trench.___ ------------------- Type of filter material-_✓� __Depth of filter material.../ or Type -length_____'.rte------------------------------ + ° Seepage Pit / Distance to nearest well_f_e----____Distance fr m foundation__=��.� Distance to nearest lot line__._ i /¢lrG1' Nurr`mber of pits_{---f-------------.Lining material_ fes-�Size.-Djameter.�• --------- - -- �, Cesspool: Distance from nearest well-----------------Distance from foundation-------------'`-:'.Lining material_____________________________________ ❑ Size: Diameter C--`------------------- ------ --Dept h__----- -- ---------r---------------------------:Liquid' Capacity-.-------------------------gals. T Privy: Distance from nearest well___________________- _____._-:._._...Distance from nearest building {' F !' -i - g -f ❑ Distance to nearest lot line ' --------------------------------.-.----------------- I I c° " � Remodeling and/or repairing (describe):_-_-___/�� -- II. _ _ ' -----=----------------------------------- _____________________________________________________________________________________? f' f-11. y+ ------------------------(.___._______ _____________ i__________-_--._______________[• ___________-____________ _;_.----_--_____ _;-_____._______-___f ______--.__-_______ _____-_-.-__.______-----______._.. ____________-__-_______________________.____ ________________-- _.__________________+ y----_.---___.___.._.__-_._._..___ I . hereby cerfify-that-I-have prepared this application and that the work will be done in accordance with'-San Joaquin County ordinances, State I ws and rules and regulations o the San Joaquin Local Health District. I(Signed)--------- -------- ----- I f'Fi'j it/-�. ------- ---------------------------- ---------------- {O ner and/or Contractor) By: - r� -- -------------------------------------------------------------------(Tale}. .. -�__t__ ------ - -- ---- (Plot plan, showing size of lot, I ation of system in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY-----,_ -------------- -----------j'-. DATE_.:j_I��Z l ----------------- REVIEWEDBY---- - ------------------------------ ----------- -------- ------ ---- ----------------------------------------- DATE BUILDING PERMIT ISSUED------------- - = -----• DATE. ; Alteratons and/ rrecommendations:_----_.__..1/ ._ _ _.__-.___ __�L- ��—�� ' --=`------- ��-------------------- --------------------------------------------------------------------------------------------------------------------------- t I ---------- ------ - ----------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------ --------------------------- ------------------------------- 1 -------------------------- --------------------------------------------------------------------------------- -------------------------------- -------------------------- ---------------------------- F1NAL INSPECTION BY:- _ I rANJO�AQUIN Date -�---`--------------------------------j r LOCAL HEALTH DISTRICT 1601 E.Hazellon Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street Lodi,California MantecaStockton,California ,'California, Tracy,California