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FOR OFFICE USE: ;' /'Z --------------------------------------------- APPLICATION FOR SANITATION v �atMIT Permit No. ----- .- ...� --------��-------------------------------------- --------------------------- (Complete in•3 Duplicate) s Date Issued __- V?;.. 1 e ------------- This Permit Expires 1 Year From Date Issued - .,, Appliiation 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. �f• ?-I JOB ADDRESS AND LOCATON--- -------- Owners'Name - s/ ----- ----------------------------------------------------------------- Phoni, ------------------------------------------ --------------------------------------- Address .---�=11-- `.. Phone ----••----•----•--------•-------••- Con4actor s Name --•----------_ _---�-----.. - ----•------------------------------------- Installation will serve: Residence ❑ Apartment House ❑ Commercial g Trailer Court ❑ Motel ❑ Other ❑ Number of living units: -------- Number of bedrooms -------- Number of baths -------- Lot size ---- ----------------- --------- Water Supply: Public system ❑ Community system ❑ PrivateAQ Depth to Water Table/0-__ 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---------------- _--- j No ❑ New Construction: Yes ❑ No ❑ FHA/VA: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: r. (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tanli_ ' ~ -Distance from nearest well_________________ Distance from foundation ------------------- Motor iai._____.__--_.______-__-____....__._..__________- { ,r No. of coin;)artmohts--------------- - depth------------------------Capacity------------------•---- Disposal,Field: Distance from nearest well. -.-..,5' stance from foundationDistance to nearest lot line____ } Number of lines _________..__ ------- Length of each line ------- Z� Width of trench.._._...-_---.-- Type of filter material___ __ _ _ __�j _ Depth of filter, material -_/x -r -.--Total length___._.l]_- ...... Seepage Pit: Distance to nearest well stance om foundation___%l1 Distance to nearest lot line___S_ iNumber of pits --------- -------Lining material. __--•- -----Size: Diameter_____ --.Depth--------------------•-- Q� Cesspool: Distance from nearest well__________ . Distance from foundation_________ __________Lining material ____---_.______-__.___...----------- Q ❑ Size: Diameter -------------------------------------- Depth----------------------------------------------------- ----------------- •--- ------------Liquid Capacity -------------g4ls, Privy:'-;, Distance from nearest well _________._____;-._____`_-.____-_;c_:`_---- Distance -from nearest:building_____________________.._______________.. Distance to nearest lot line - --- - i-------�-----------------------•---------------- ---------------------•------- ❑ Y .r•t .. F ---•______..... ,Remodeling and/or repairing (describe) -------------------------------------------------------------------------•-••---------------------------- ---------- # x -4 t ------- --------- --•---------- i I eby certify that 1 have prepared this applicatiot}.i3n ,that the work will be done in accordance with San Joaquin County ordinances, Stde laws,'�}n_d runes and reg. afions of the :SanJoaquin Local Health District. r . - ` r ----- wner and/or Contractor) (Signed) �1��✓ I B � d _� *i(� ° 'I� _ .fit- --------- ------------------------------------ (Title}_- I .Y� r (Plot plan, -showing =size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). i FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY--- - +- -`- `----------- ---------------- DATE------- � •----------------------- REVIEWED - ----- REVIEWEDBY--------------------------------------------------------------------------------------- ------------------------- ------ DATE ------------------------------------------------------------ BUILDINGPERMIT ISSUED----------------------------------------------------------------------------------------•- ------ DATE----------------------------------------•-------------------- Alterations and/or recommendations ------- ------------------ - - -- ------ - - ----------•-----•--•---- FOR_..--J�DAt_��ol�.--------To--------h-1T�+�I ---------6---�'r"�M------ 0-1��- -------•--•-------- ---------------- --- --------------------------------- -------------------------------- -------------------------- -- --r ----•-------±---------------------------------------- - -------- -------- �---------------------------------------------------------------------------------------- ------------------ I FINAL INSPECTION BY:j , Date ----------- - ."- � -=------------------- •---------------- 130 South American Street Stockton, California EB -9 "EV,BEO B•B9 F. F.0 O2M 6.67 SAN JOAQUIN LOCAL HEALTH DISTRICT 300 West Oak Street 124 Sycamore Street tocil, California Manteca, California 205 West 9th Street Tracy, California