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Af FOR OFFICE USE;- -------- --- ------------------------------------------ SE`------------------------------------------------------- ------------------------------- - APPLICATION FOR SANITATIOK—RMIT Permit No. 12'� ----- -------------------- -------- -------- - (Complete-.m Vuplicate) - --------------------- ---.._._ 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. OSS J08 ADDRESS AND LOCATION-_��914AI F.ZS _ ---------I/ 41 rl / I �!- -�. _ Phone- = =- Owners Name---/- ''---ti "_ --' - ----- Address__. _- G-r -- ---------�-------•--------� � Contractors Name--------------------------------------------- --------•--------------------------------------------------------------------------- ----- Phone----------------------------------- ; Installation will serve: Residence ❑ Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other f' Number of living units: __1---- Number of bedrooms -------- Number of baths -------- Lot size -----------------__---.-._..____----_----------._.-_-___-_ Water Supply: Public system ❑ Community system ❑ Private'm Depth to Water Table --------- ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam, Clay,❑ Adobe ❑ Hardpan ❑ Previous Application Made: (If yes,date--------------------) No I] New Construction: Yes ® No ❑ FNA/VA: Yes ❑ No?:[] TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tank: Distance from nearest well_.f '__---.___Distance from foundation_-. ----------MateriaI_..-:G _'P Anni No. of compartments a Size_*. t._�Y-__----�----------Liquid depth---------------- ------ -Capacity---------- ------------ Disposal Field: Distance from nearest well---- .-----Distance from foundation---/- -----------Distance to nearest lot line----------------- A, Number of lines___._eL---------------------------Length of each line----------------------------.Width of trench----------------------.--.--------- Type of filter material------------------ -Depth of filter material------------------.----Total length----------------------.--------__-----___. Seepage Pit: Distance to nearest well--------------------_Distance from foundation--------------------Distance to nearest lot line_----_----___ ❑ Number of pits----------------------Lining material-----------------------Size: Diameter-----------------------Depth--------------------------------- 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 --_------- ------.----_----...____._-.-.Distance to nearest lot line-- --- -------- --------------------------------•-----------------------------------------------------------•----------------- --------------- f Remodeling and/or repairing (describe):--- ------ ------------------ --- =-- �- A---- *---- --------�r -- ------- ------------------------------------------------------------------ -------------------------------------------------------------- -------------------,------------------------------------ ------------ 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 rules and regulations of the San Joaquin Local Health District. (Signed)_ c. Jr #r __Owner and/or Contractor r � B �?� r.= `:F.r° ------------------------------------(Ti+le)--- i .1-"-`---------- -------- -------------- (Plot plan, showing size of lot, focition of system in relation to wells, buildings, etc., can be placed on reverse side). 1 FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY,2--_';t- ---- --------------------------------- -------- ---- - REVIEWEDBY------------------------- ----------- ----- ------------- --------------------- ---- ---------- ----------------------------- DATE---- ----------- ------------------------------------------ BUILDINGPERMIT ISSUED--:----------- -------------------------------------------------------------------------------------- DATE-------------- --------------------------- ----------------- f Alterationsand/or recommendations:------------------ --------------------------------------------------------------------------------------•------------------------------------------------- ----------------- -------------------------------------- - - --- --------------------------------- ------------ ------------------------------------------------------------------------ ------------------------- --------- ------------------ -------- ---- - ----------------------- ------------------- ------•------------------------------------ ------ --------------------- -------------------- FINAL INSPECTION BY:..- � 7Da --- 7 _- ---------------- 7---------------------- SAN JOAQUIN LOCAL HEALTH ISTRICT N 1601 E.Haxelton Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,California imig— Manteca,California Tracy,California F.F.r a.