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FOR OFFICE USE; ------ --------------------------- :5 - �- 3 0 APPLICATION FOR SANITATION PERMIT Permit No. ...,1. - ---- ----------- ----- '- 6-- --------- / -- (Complete in Qu Uca+e ----- --. .. P P ) 3 b ----------- -- 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 t ork herein described. This applications is made in compliance with County Ordinance No. 544. JOB ADDRESS AND LO TION---- _.,> `�"` r '�. - -"" f .......__.! ...... .. -------- - - .................. Owner's Name..............:.... -C -4' --.... Phone _. 7 Address------------------------ ------•----•------........ ------.. Contractor's Name--•tom......... i .. .c, .-- `'-4'` ----------------------------------•--- . Phone—, ? -•---..... . Installation will serve: Residence parfinent House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: .... Number of bedrooms _/_ Number of baths _f"__ Lot size ...... ---�._�'-_-_-41 `` Water Supply: Public system ❑ Community system ❑ Private ❑ Depth to Water Table 0 ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ A6beA_Hardpan ❑ Previous Application Made: (If yes,date--------------------) No ❑ New Construction: Yes ❑ NO__Z FHA/VA: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if p blit se .er is available within 200 feet.) F Septic Tank: Distance from nearest w t Distance fr m f fion____ _ --1 Material_` -... . . No. of compartments_____-_______'___.__Size. o.. .X_�=___Liquid depth_... "__ -----Capacity...r �.. . Number of lines______ _____.� Length of each line------- ._____-.Width of french__ line ........... Disfance to nearest,lof �/ Dispo l Field: Distance from nearest well-711-0_ �--...Distance from foundation._ Type of filter,mater�l. ____ -------Depthof'filter material__JX'l__�._Total length.......' - ........................ Seeps a Pit: Distance to neares wall __ _ ____Distance m fpundation__� _-_._. is a�ie to nearest lot Ii Number of pits_____ _______________Lining material_____�_C_._�__t_rf(.a_.___5ize: Diameter- _--_.-.._.-.Depfh_ ___._..__________ Cesspool: Distance from nearest well.................Distance from foundation--------------------Lining material ._____-____._....................... ❑ Size: Diameter------------•-------------------------Depth------------------ -_ -------------------------Liquid Capacity............................gals. �.. PPriv Distance from nearest well._._________--- Distance from nearest building * _____________ rivy: -----•-------------- g------------------------- Distance to nearest lot line--------------------------------------------- Remodeling and/or-repairing- -describe--- � �' --- 6 a, '---••.-----•---------------------•---------------------------------- i ------------------•-------•--------_----_---•---------------....----------------------------------------------•-•-------------•-•--------- ----------------------•---------------------------------------------------------------------•-----••-•-------- --------------------- I hereby certify that I have prepared this application and,that,the work will be done in accordance with San Joaquin County ordinances, Stat laws, and rules and regulations of the San Joaquin Local Health District. _. r-� (Signed) =� - -c-Lt ..-- , J r-------- IV-A---- ----------------------------------------- r Contractor) . By:........................................--------------- •-- ----- f (rifle)----------------------------------=°�--- .-.------------------ t (Plot plan, showing size of lot, location of system in relation t ells, building), etc., can be placed on reverse side). OR DEPARTMENT.USE ONLY APPLICATION ACCEPTED BY_______ ------------ DATE REVIEWED BY---------------------- -----------------=---------------- ---•---.........._.:._._ DATE----------------•--------- , BUILDING PERMIT ISSUED ------------ DATE - - .. - Alterations and/or recommendafions:__-- .-- --' _ ---- ------ '.-----_Q -- - ----------- ---•-- -�Pl/- s -----------------------------*------------------------------ --•-----•------------------*------------------------------ ------------------------••-------------- r FINAL INSPECTION a ...----. .... x 1 .- Date. �- ` 2SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Srr"t 124 Sycamore Strout 205 West 91h Street Stockton,California Lodi,California Manteca,California Tracy,California ES 4 REVISED 8•99 7M 5-61 ATLAS i