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FOR OFFICE USE: ----------------------------------------------------- APPLICATION FSR SANITATION PERMIT Permit No. d�QQ --------------------------------------------------------- (Complete in Duplicate) Date Issued _____ ___ ---------- .__. --- I This Permit Expires 1 Year From 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. 13 -- 4-T ps JOB ADDRESS AND LO/CATION_____ DSr___N �_•,�t •�.I� -_./_ _ Owner's Name-------t7`I/YC/ 01Y_ _G eQj / f �Pidte%jQl t7`_C��hone-----------•------------------------ Address----•---/V"_� _ `tY ----------•-------�'L-�G1L-r rl- Contractor's Name------- --------- ------------------------------------------------------- ---------------- Phone----------------------------------- Installation will serve: Residence ❑ Apartment House ❑ Commercial railer Court ❑ Motel ❑ Other ❑ Number of living units: __ Number of bedrooms -Number of baths -_Y"- Lot size __- �K ---------------- Water Supply: Public system ❑ Community system ❑ Private ❑ Depth to Water Table -------- ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe [B—ITa rdpan ❑ Previous Application Made: (If yes,date---------- ---------I No ❑ New Construction: Yes Ea—I'ln ❑ FHA/VA: Yes ❑ No E�f TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted ifpubli sewer is available within 200 feet.) ,pQ o Septic T11 a Distance from nearest well :'__Distance from foundation__./(?t--------.M ateriaiW,0-- � i No. of compartments---------- --------- Liquid depth----�37--.---------------Capauty_•--171'4-_&: Af ") Disposal F Id: Distance from nearest well_ai0_1`-----_Distance from foundation—/ ._-.___Distance to nearest lot line--- Number of lines-----------moo---------------------Length of each line-----------1 ----------Width of trench---.-.z_ .��---------------- Type of filter materiaL� te __Depth of filter material_._______/_I f�___..___Total length_____-_GQl3-'________--_______-_. Seepage P Distance to nearest ...........Distance from foundation___AV ___.__.Distance to nearest lot lineJ_-_moi" a'-._ Number of pits._.__�Q----___---Lining matenal � _-Size: Diameter__-_ ....__-____Deptn_...___-?r_s�_________________ Cesspool: Distance from nearest well----------------Distance from foundation_------------------Lining material____..._____-----._-____..________.__ ❑ Size: Diameter--------------------- ------------ ---Depth-.------- ---------------------- ------------------Liquid Capacity-.--------------------------gals. Privy: Distance from nearest well-----------------------------------------------.-Distance from nearest building------.---------------------------.-_..._. ❑ Distance to nearest lot line----- ------------------------------------------------------------------------------------------------------------------------------------- Remodelingand/or repairing (describe)---------------------------------------------------------------------------------------------------------------------------------------------------------- --------------------------------------•---------------------------------------•--------------------------------------------- ------------------------------------------- ---------------------- ------ ----------------------- --------------------------------------------------------------------•------------------•------------------------------------------- ---------------------------- I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State ws, and rules and regulations of the San Joaquin Local Health District. (Signed) -------------------------------- ---------------------(Owner and/or Contractor) SYaQ-O------- - -- ---------------- ----------------------------------------------(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 APPLICATIONACCEPTED BY----- ------- - - ------ -- -------------------- ---------------------------------------- DATE---------�01 �--------------------------- REVIEWEDBY----------------------------------- - ----- ------------------------------------------------------------------------------ DATE-_------------------------------------------------•-------- BUILDINGPERMIT ISSUED------------------------------------------------------------------------------------------------------ DATE--- ------------------------------------------------------- Alterations and/or recommendations:----------------- -------- ---------- -------------------------------------------•--------------------------------------------------------------------------- --------------------------------------------------------------------- ------------ -----------------------------------•-------------------------------- ------------------------- ------ ------ -------------------------------------------------------------- --------------------------- ------------------------------------------ ----------------------------------------------------------------- ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- - --------------I---- ---------------------------- ---------------,,-,,- ----------- - ------------------- - ------------------------------------------- ------------------------------------------------------------ FINAL INSPECTION BY:.-.._._.-�..,rt�� ------------- Date-------------------S//f&/Arm SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Hazelton Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street r� Stockton,California Lodi,California Manteca,California Tracy,California F.P.CO.