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I-UK UFI-I(_E USE: s=1� �------------------a� �J_.__ , __________ ___________ -- ------------------------------- APPLICATION AOR SANITATION PERMIT Permit No. . Q_Z/--4/-4 3 .� (Complete in Duplicate) --------------- 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. JOB ADDRESS AND LOCATION __5_ _ -------7------ _ Owner's Name------- 7_0217i ------------------------------------- ----------- -------------------------- Phone----.------_------------•-----•---- Address-------------------•----•- ---P. ) Contractor's Name------------------ ``jja�----------••----------- ----------------------------------------------------- ---------- ------ Phone----------------------------------- Installation will serve: Residence--fApartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ g �___ Number of bedrooms---- _ Ira a Number of living units: __ .� _ Number of baths >___._ Lot size -- ---- �________.-------__._.___ Water Supply: Public system I,Q Community system ❑ Private ❑ Depth to Water Table�6_ ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ ,$ancly foam ❑ Clay Loam ❑ Clay ❑ AdobgV Hardpan ❑ Previous Application Made: (If yes,date._.-----------------) NON New Construction: Yes ❑ No ❑ FHA/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 welt_"___: __Distance from foundation_ ___ __.. Material j !%E'j ___ ___ No. of compartments-------------:..___.____Size___ _ � _ Liquid de th____.___ _Ca p acit __ C�__7ql" Disposal Field: Distance from nearest well........._--------Distance from foundation___ _(_1... -------Distance to nearest lot line___ ------- Number of lines________ __ - ------.3------- _ --Length of each line_____ __--- ----------------Width of french,-------2-�------------------ Type of filter material------- ;_ -•-_____Depth of filter material____._��-- -Tata! length- --!/".6 -a---------------------- Seepage Pit: Distance to nearest well---------------------- from foundation--------------------Distance to nearest lot line_______ ------ ❑ Number of pits----------------------Lining material----------.-------. __-Size: Diameter------------------------Depth--------------.---------w--- --- �,. Cesspool: Distance from nearest well-----------.-----Distance from foundation__------------------Lining material-...___-_-------------_._.________-- ❑ Size: Diameter---- --------------------------------- Depth_ -------------------------------------------------Liquid Capacity----------------------------gals, i Privy: Distance from nearest well_________________________________________________Distance from nearest building--------------------------------- ❑ __.___... Distance to nearest lot line--------------------------------------------------- ----- f' Remodeling and/or repairing (describe) cl pf �dr9 rJ°�,----------f'{�4� � f ----------------------------------------------------------------------------------------------------------------------- - ----------------------------------------------------- -------------------------------------------- ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ----------------- --------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- -------- I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County } ordinances, State lows'. and rules 4pd regulations of the San Joaquin Local Health District. (Signed. ----------------------------------------- - - - -------------------------------------------------(Owner and/or Contractor) B (Title)_ } (Piot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). 3 r R DEPARTMENT USE ONLY APPLICATION ACCEPTED BY----------- - ------- ---------------------------------------------------------------------- DATE--------- REVIEWEDBY------------------------------------- -- ----------------- --- ------ ---------------------------------------- DATE------------- ---------------------------------------- BUILDING PERMIT ISSUED---------- --------------------------- --- --------- -- --- - ----------- DATE---- --------- Alteratio s and/or recommendations:_________..____ .� .- -( :__ :#v _ ..w'r . ' ;sea =.,--•-- �tz.e FINAL INSPECTION BY:....PS/ ___ Date._..___ _.�_.. _ 4 QUIN LOCAL HEALTH DISTRICT 1601 E.Ha:ellon Ave, 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,California Manteca,California 'Tracy!C9lifornin 4 � f