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FOROFFICEUSE: i EI. APPLICATION FOR v SAN{TATION PERMITPermit No. ._!___ ' l _ -A�---------.-. _ --------------L---------------- --- ---------------- (Complete in Duplicate) �� ---------------A-------------------:.---.----------.-.- This Permit Expires 1 Year From Date Issued Date issued Applhcation 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./.�� A04-7�`.....it7r 4/�- --- -=--=----• i , a_` Owner's Name----------- ltJ ? Phone.. Address -------•---�*�-".4... ' �' Contractor's Name------------------------- ------------------------------------------------------- - •----------------•--------------- Phone------------------------•---------- Installation will serve: Residence ER""Aparfinent House ❑ Commercial ❑ Trai/ler Court ❑ AMotel E] Other Number of living units: ---- Number of bedrooms _-- Number o baths --1.-._ Lot size -- -e_t '. ------------------------ Water Supply: Public system ElCommunity system E] private epth to Water Table ft. Character of soil to a depth of 3 feet: Sand ❑ Grovel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe ❑ Hardpan El--*" Previous Application Made: (If yes,date.-------------------) No New Construction: Yes [ KNo ❑ FHA/VA: Yes ❑ No P.J' I TYPE OF INSTALLATION AND SPECIFICATIONS: tank ep (No'-stic tk`orces - spooptp l ermited-if public sewer-is available within 200 feet:) - li. Septic-Tank: Distance from nearest well------------_---Distance from foundation--------------------Material---------------.-----------.--------------------- J%. No. of compartments---------------------- Size--------------- -------- ---Liquid depth--------- -- - - --------Capacity---------------�----- Dispos 4?ie Distance from nearest wel_ - istance from foundation-- _-Distance to nearest Ii Number of lines-------__-.- ength of each line--------- �_ Width of trench.-- , r Type of filter materia _ ..-. epth of filter material----.-- Total length-------_ /-_.---- See 'age Distance to wrest well- -� "--stance from foundation---jef�--.Distance to nearest lot {ine--J_.� V ' P Number of " ------I--------- Lini�n��g material- (�E.[�1 ..Size: b r with----- -- - --__-_-- Cesspoo4 Distance from nearest well-----------------Distance from foundation------------.-------Lining material---.-------_-------_-_--_--_----. M. Size. Diameter-------------------------------------Depth------------- --------------------------------------Liuid Capacity Privy: Distance from nearest well-------------------------------------_----- -.-Distance from nearest building---------------------------------..------- Distanceto nearest lot line----------------------------------------------------------------------•--------- ----------------------------------------------------- ----- Remodeling and/or repairing (describe):_- 116 ll-"P_f2 ------ +' /------------------------------------------ ¢- ------------------------•------••-----------------------•--------------------------- ------7---- ------------------- ------------ 1p------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ -I - ------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------ ---- - 11 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. I (Signed)-- " -------- ---- r_".Qp -Owner and/or Contractor) By:------------------------ ------------- ----------------------------------------------------------------------------------------( i e---------- ----------------------------- ------ (Plot!plan, showing siz0of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). fi FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY - ,� -------------- ----------------------- DATE--- _ �"' ''� - REVIEWED BY------------------------------- i�-.-. .I' cL S' -__Of=iq----_------------------ DATE-------------------------- BUILDINGPERMIT ISSUED---------------------------------------------------------•----------------------------------------- DATE-------------------------- ---------------------------------- Al ra ons d/or re ommendations:-------------------T- ------- I ---------------------------- ------------------------------------------- -------------------- -------------------------------- ------------------- - -- -------------------- ------------ - ----------------- ---------- - -------------------------------------- --------- ----- -------------------------------------------- FINIAL INSPECTION BY:.. Date -- -- -- s-- ----------------------------------------- i SAN JOAQUIN' LOCAL HEALTH DISTRICT 1601 E.Hazellon Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California Lodi, California Montecar California Tracy,California F.P:co. x