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FCiZ OfFrCE USE: APPLICATION FOR SANITATION PERMIT "Permit No. 3 --------- ----------------------------------------- (Complete in Duplicate) f This Perrhit Expires 1 Year From Date Issued Date Issued _3-__-�__ t 2 `f� -- x•2.3_0f a 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 complia ce with County Ordina.ce.- o.,.5 9:.. r �. t C' _4 -r::c . JOB ADDRESS AND Loc AT -----------Rl1f. -----1/t�� _lrl.�/g�� - NIN�.��+-------- --- -��---{---- ------�--- . R Owner's Name---------.LAR-------` `IC��R� �� ----------- --- l; Phone_..... Address---------1---------j�-z---------N.Q------6RA _..-`-------�------- --- ----------•-•-----.-----------.----------- ----•---------------------- Con#ractor's Name _ ! ---•--------------•--------------- ------- ------,---------------------------------- Phone. Installation will serve: Residence [LYApartment House oA Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: j---. Number of bedrooms__. Number of baths _2 Lot size _--- --- ------------------ Water Supply: Public system ❑ Community system ❑ Private [Depth to Water Table Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam Clay Loam [ Clay ❑ Adobe ❑ Hardpan ❑ Previous Application Made: (If yes, No Rf New Construction. Yes ❑ No+Ej--__FHA/VA: Yes ❑ No ®— x TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank 6r cesspool permitted-if public sewer is available within'200-feet: ,nearest well----. ._.__-Distance from foundation--------------'_ Material____ _____________ __ _______________________ Septic Tank: Distance from, E�ISTI A(C-- No. of comparfiments'-- -----------------SizeLiquid,depth----------------- --- ----Capacity----------------------- � Disposal Field: Distance from nearest well'_�0__.__Distant e"dfromtf6u cia'tion_____ .. .- l�_-----.Distance to nearest lot line____-__--______ . QrW .____.._- _ F—XEPT(Ker- Number of lines--------- Length of each line-__--- __-_ r --_--- Te•ofilter material� C,+ DD yR. -' - --------------- 0 Seepage Pit: Distance to nearest well.____.___'"` "'"D:'isfan'ce from fou illation--------------------Distance to nearest lot Rline___-.._-----.--_.____-.-- ealS : Diameter.-----------------.___-Depth..----------------------❑ Numberofpits------------- --•- Lining mat Kyi1;.- Cesspool: Distance from neares# weal_____ ________`Distance from foundation- .------- --_-._.Lining material__-.____--.-----_-.______----_----- 9. [l Size: Diameter---------------- --------- ---- Depth----------------------------------- ---------------Liquid Capacity----------------------------gals.( Privy: Distance from nearest-.w'eIL-------------------------------------- --------Distance from nearest building------------------------------------------ 'r sta�o..rlea""rest lot line---------------------------------------------------------------------------------------------- - --------------------------------------- ----- Remodeling and/or repairing (describe):------- -------------------------------------------------------- -------------------------10..--------------------------------------------------------------- --------------------.. ------ T ' --------------------------------- - ---------- f _------a--------------'--------------------------'-------- S 'r --------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- .-_----- 4 I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County i ordinances, S e laws and es and rec�ulatio s of the San Joaquin Local Health District. (Signed) -------------- - ------------------ - ---- ------------------------------------------- (Owner and/or Contractor) --- - - (plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). �M '¢ ►� . FOR DEPARTMENT USE ONLY KQY- F 'R _ ----------------- DATE----------�_�- 2Si- 5 APPLICATION ACCEPTED�ED BY . - 'Q---------------- -----•--- --- ' � -- -- REVIEWEDBY-------- --- ------------------------------------------=---- - --------- ------------------------------------------- DATE_.-.----------------- ----------------------- -------- BUILDING PERMIT ISSUED----------------------------------------- "OV -_ DATE--------- =------ Alterationsand/or recommendations------------------------------ ----- --------- --------------------------------------,-----------•------------------------------------_--•---.-_------------- ----------------------------------------- --------------------------------------- --------------------------------------------------------------------------------•-- -------------------------------------------------------- --------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------ FINAL INSPECTI BY• _ �,]._ ----- ---- 'j Date------------Lf�. / - ----- ------ ---------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Haseltan Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,California Manteca,California Tracy,California F.P.CO.