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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT Permit No. ..... .T`'!_:5.....1 �- 1 (Complete in Duplicate) (o Date Issued 1..---- ----------- __ - _._.___""_' ` ' This Permit Expires 1 Year From Date Issued J 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 wit +County Ordinance No X549. l JOB ADDRESS AND LOCATION /I'"1'""" ------------•-_i -----------•--•-••-•----•------------•------•-•-----------------•---- � / , Owner's Name-------- f.......V -------- ,A,./- .y-------------------------- -•---•--------- Phone........--................. Address............7:..6).-.---- -------•----..�- l .. ; _ - o-7 ContractorsName-------------------------- _---- �--�7.___....Z! -- -----------...._....--------------------------•------------- Phoney Installation will serve: Residence ❑ Apartment House ❑l Commercial [] Trailer Court ❑ Motel ❑ Other Number of living units: -------- Number of bedrooms -------- Number of baths ---•---- Lot size h Water Supply: Public system ❑ Commuriity system ❑ Private Depth to Water Table4 ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay Adobe 9 Hardpan ❑ Previous Application Made: (If yes,date--------------------) No Ej New Construction: Yes ❑ NoW FHA/VA: Yes ❑ No EQ TYPE OF INSTALLATION AND SPECIFICATIONS: �- CN (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tank: Distance from nearest well----------------.Distance,from foundation--------------------Material---------..................................... ❑tic�r►Al No. of compartments-----------------i-------_Size---._._.....____________.--- --Liquid depth------------- r Disposal Field: Distance from nearest well_________________Distance from foundation____.....______._-_Distance to nearest lot line......... �:.. 0€K,c-0/1 Number of lines---------------------_----------_Length of each line------------------------------Width of trench.............--•--------------•;;-- Type of filter material_________________________Depth'of filter i material____---_-.-- __._Total length--------------------�_______ is '' Seepage Pit: Distance to nearest well__ApCZ__.__---Distance from foundation../Z_.........Distance to nearest lot line_7_. ...... Number of pits...----------.Lining material_/ G --------Size: Qiameter ��---4g��..Qept �-----•-------------•-- Cesspool: Distance from nearest well----------_......Distance from foundation___._t-------------Lining material----------,----------------.------ :.. . ❑ Size: Diameter--------------------------------------Depthe--------------- -----------------' --------------Liquid Capacity............................gals. Distance from nearest well --_-._____----___Distancelfrom nearest building------------------------------------------ Distanceto nearest lot line- - -------- ----------- ------ ------------------------;--.....-h--------•-••-----------..........------•-------------•----...----:-- + // a Remodeling and/or repairing (describe):------ x_i. -------� *----- ------•-------•---•--------......� -•-•-----------------------------..... ------------------------------------------------------------•------------------- ---------- ------------------------------------------------------------------------------------------•------ ----- - 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 rule nand-fevulations of an Joaquin Local Health District. 41(Signed)---------------------------- --•• ----- ---- --------- F (Title}___...__. {Owner and/or Contractor] �� / �! By:------------------•-•-----•-----• ............. (Plot plan. showing size of lot, location of system in relati n to wells, buildings, etc., can be plac4d on reverse side). t I FOR DEPARTMENT USE ONLY APPLICATIONACCENTED BY...... - - ------------------------- -- -------------------•-------------------- DATE- ---------------- REVIEWED -------REVIEWED BY-----------------------------..............-------------------------------------------------------------- -------------•-•- DATE--------.---•-------....-------••--•------------------ - BUILDING PERMIT ( .,,�..._ ISSUED--------------------------------------------•-•--- °----------`---------•-•-•DSATE--------------------------------------------------------- - ---..•.•.- -------------------------•--•---•------------- --- tAlferatons and or recon enctaions:___� --_.___1S _-- i! ... = :.. ------•----------- _ -----------•------------------ rt FINAL INSPECTION iBY: L-� Date--- _'._ _-_ [?.z"..------------------------•--.._..---------•--...... SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 Weft Oak Srreet 124 Sycamore Street 205 west 9th Street Stockton,California Lodi,California Manteca,California Tracy,California E6 9 REVISED B•69 2M 6.61 ATLAS