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/#_ )kVrrK t UJtc ' ...� .................. -----------__.......... _______ APPLICATION FOR SANITATION PERMIT Permit No. - --------- --------------------------------------------- (Complete in Duplicate) Date Issued --------------------------------------------------------- This Permit Expires I Year From 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. a� JOB ADDRESS AND LOCATION-------.� - - -------------• Owner's Name- -- . �`°A-----� � ----y---�----------"-t -----L----l_----C--7---- ----Y- Phone''��_�_"_��' Address------..... t 40-2------ G� T, TTD Contractor's Name-------- installation will serve: Residence IK Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: --- Number of bedrooms ---I_._ Number of baths __4-__ Lot size __--_________________ Water Supply: Public system IN. Community system ❑ Private ❑ 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 JK New Construction: Yes ❑ No Q FHA/VA: Yes ❑ No 0 TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permiffed_if public sewer is available within.200 feet.)— Septic eet.) -„Septic Tank: Distance from nearest welL_______________ Disfance,frorq,foundat'ion_-./e__-_'-----Material__ E_` ! __._._._. p �---- �XIQ_'.Liquid depth--- �: fs----- p y-- -- No. of com artments-..___ Size__ _ _________ _ Ca acit _�¢�� Disposal Field: Distance from nearest weii___________�_._Distance from foundation_______________'____.Distance to nearest lot line----------------- ❑�ikl liN�' Number of lines..................... Length'of each line------------------------ -----Width of french---------------------------------- Type of filter material---------------------.__Depth of filter material___________ ______---- otal length_-_-_-_._________:__________________- Seepage Pit: Distance to nearestwell-----------------:_��._Qistance from foundation--------------------Distance to nearest lot line_____.___.____. ❑ Number of pits--.-------------------Lining material___------ -----------Size: Diametei-------------.----------Depth---------.----------------------. .J Cesspool: Distance from nearest well_____------------Distance from foundation--------------_-----Lining material------------------------._____-----_. ❑ Size: Diameter-------- Depth----------------------------------------- �----Liquid Capacity---------- ---------------gals. Privy: Distance from nearest wellt__4a�__ ''_ ...- { -----------------------Distance from nearest b0ding-.---------------------------------------- F1Distance to nearest lot line. ` ----------- ------ ------------------------•---------- ------------------------------------------------------------------- � I Remode4ing and/or repairing (des5 ibe):___ C - .----- i �-�----- / .� 1 ------------------------------------ f --..�,. ---------------- ------------------------------------------------------------ - -------------------------------------------------------------- ----------------------------------------------------------":-- -------------------------------------------------------------------- E I hereby certify that I have prepared this application and that +he work will be donne in accordance with San Joaquin County ordinances, State laws and rules and regulations of the San Joaquin Local Health District. ,E Si ned � ,.rte "+ �._•. �`�. ( g )_--- J'r �r ��- � ..�-J C�� -----------------------------------------------------------------(Ow r and/or Contractor) ee By:-----------------' -� :.�.�4 _.. ---------------------------------------------------(Title)----- — -----t------......................... (Plot plan, showing size of lot, locatiou/of system in rela+ion to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY------ _ _ - __ ------ -=-`------ --- --------------- ------------------------- DATE---- REVIEWEDBY----------------- ----------------------BY -------------------------------------------------- ------------------ DATE BUILDINGPERMIT ISSUED---------------------------------------------------------------------------------------------------- DA•TE--------- --------------------------------- Alterations and/or recommendations: `'-._- _^" - ----------------------------------- --------------------------------------------------------------------- ------------------------------------------------ - ---------- -------------------------- ------------ ---------- ------ --- --- --- ---------- ---- ------- --- ------ --------------- 1 4, \ 1Z --------------------------------------------------------------------------- -------- --------- ----- -' r -•------- -------------------------------------------------------- FINAL INSPECTION BY:. .. _.____ - Date----------- --- 2 .. ----------------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 7601 E.Ma:elton Ave. 300 West Oak Street 124 Sycamore Street 205 West 91h Street Stockton,California Lodi,California Manteca,California Tracy,California