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FOR OFFICE USE; GG //,�34 ----------- - ----------- ----------- ------------------ APPLICATION FOR SANITATION PERMIT Permit No. ..-.- -•-•. -...-- . ------------------------- --------------------------- -- (Complete in Duplicate) - -------------------------------------------------- This Permit Expires I Year From Date Issued Date Issued :_7 Z Z- Application is hereby made to the San Joaquin Local Health'District for a permit to construct and instil 1 the work herein described. This application is made in compliance with County Ordinarice,No.�k549, JOB ADDRESS AND tOCATION-,------ / v l' Lam,` 1��'-- Owner's Name------- "l ._ Phone _ . Qo� Address VJE�� ------ 1� ------------ --- -------------•----------------------------------------------------------------- ----------------------------------------------- Contractor's Name 1. -J7` /'� l-sX----------------- ---------•-- --------------------------------------•------ Phone---------------------------------- Installation will serve: Residence A'artm`e t�House,.�`Commercial Trailer Court Mo' tel�❑ ❑ ❑ Motel ❑ Other ❑ N ber of living units: _ J[___ Number of bedrooms ___Z.""Number of baths .- Lot size ------- _ n i y� y` f ....-------------------- �t � _r.- rt e� �., l II Water 5 pply: Public!syster>3 ��Gommunitysystem;❑: Prrvete<,I] Depth to Water Table __..____ ft Character of sail to a depth of 3=fe t Sand'❑ ,'Gravel1� `Sandy"Lb- m ❑ Clay Loam ❑ Clay 0 Adobe ❑ Hardpan ❑ Phevious.�4pplica+ion Made: If yes,date 1 No ,+ -- e l Y, ❑ New#Construction: Yes ❑ No ❑ FHA/VA: Yes ❑ No ❑ TYPE OF4INSTALLATION AND`SPECIFICA (No septic tank or"c"esspool permittedii public sewer is available within 200 feet.) Septic "rink: Distande from ❑ : nearesteol ____ Material No - -------------- ofcompartments__ - ---------- ---------Size------------------ Liquid depth---------------}--------Capacity----------------------- DisposalFiold: Dis�an�e`from nearest well'_==.: .:. �rQistante>from.fon dation___3ali Disfance #o are, lot line__,l _�__ t ISI Yp p _, ,s�.-�i --649-----Width i/ --- Number of lines______.____�_�__ Len th of each liney___.___- f +rea __._______- -- T e of filler material___ _-_De---Depth of filter matenal____._� -_�1_._Total lengfih_._._____ Q __________._�._ Seepage Pit: Distance to nearest well_.____ Distance from fo ndtion______ j----- fio nearest lot line__, _____ X Nutuber of pits------- ___.Lining material__ ___SNize: Diameter....._8". __.Depth--P-5 � Cesspool: Distance from nearest well_____________ - Di anc6 f m found tion.___-.____-__ _Ailg m 3teri8l---- w.. - ❑ Size: Diameter- - -------- --..De fh-----------------------I------------------ iguid Capacity-. gals. Privy: Distance from nearest well-----------___________-- __------._________._._Drestdbuil Distance from ine� ding_ ----._.________.___________.___.------ _. ,. ❑ Distance to nearest lot line---.-------- ,.=---- ------- - Remodeiin and or re airin describe _ . _ __ �j� y l-- ----------------------------------------------------- ------------------------------------ -- ---- c--- -: ------------------------------------------------------------ ----------- -- . -------------------------------------------------- ' -- ---------------------- I hereby certify ta+ have prepared+his application and}hat the work will`be done in aac orda�cewith San Joaquin County } ordinances, State laws, and rules and regulations of the San Joaquin Local Health District. ' (Signed)------_,!/+ - - --- - -- - '-- ---- -- -_ fit_ �i7G ____Owner and/or Contractor By:.- ----------------------------------------------------------------------------(Title)--- `------- --- .... ..------------.... (Plot plan, showing size of to ocation of system in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY i APPLICATION ACCEPTED BY--------- - ` 1 - ------------------------ ----------------------------- - - ---------- DATE-----/--�'-,7-+----� --------------------------------- --------------------------- ------- - --------- i REVIEWEDBY-------------------------------- ------ --------------------------------------------- ----------------- DATE------------------------ ---------------------- BUILDING PERMIT ISSUED----------------- ---------------------P------------------------- DATE.---- --- ------------------ Alter tions and or recomrrlendations.__ ___7'-�6-______- 5 ' art _<h �,�Yst ��••^^��- --r`!- ------ ------ art-»n ------ 4 --- ----- e'. ej-----A/lonf�l+ i ------. su ✓ � ' = � -------------------------------------------- -- - - //V --------- - - ---------- : / moi' o � P�-, --��y- �l��as ------------------ ------------ FINAL INSPECTION BY:-----._. _ Date--.- -- --._^ '_(1_ _---------- ------------ - -- - - ----------- S J QUIN LOCAL HEALTH DISTRICT 1601 E.Haselton Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,California Manteca,California Tracy,California F.P.r.O.