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FOR OFFICE USE: j su APPLICATION FOR SANITATION PERMIT Permit No. .121-62S .. [Complete in Duplicate) Date Issued -- -f� � -------"--"---------------_----.-_.-...-.-------" -...- This Permit Expires 1 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 incompliance with County Ordinance No. S49. n JOB ADDRESS ANQ LOCATION - ��Vif--4,26/7------------------------------ ifx, ------��/�� Owner's Name --1- Q 7� L-f7---•---------------------------------------------------------------- ------------------ ----- Phone-----------------------•---------- Address-------- ---------Address-------, rJ-L_ .. .. i - A--------------------------------•- Contractor's Name--------- --------------- ----------------------------------------------------•-------- Phone----------------------------------- i Installation will serve: Resi,ence ❑ Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other (-- Number of living units: - Number of bedrooms --'" ` Number of baths 2--- trot size 0G-t�4-_`---------------------------------- L 11 III! 'J [r. Water Supply: Public system ❑ Community system Private ❑ Depth to Water Table ft. Character of soil to a dept of 3 feet: Sand ❑ Gravel ❑ Sandy Loam.❑ Clay Loam ❑ Clay ❑ Adobe Hardpan ❑ Previous Application Made`: (if yes,date-----.- `:___"") No 2"" New Construction: Yes F!rNo ❑ FHA/VA: Yes ❑ No E--q TYPE OF INSTALLATION!AND SPECIFICATIONS: } (No septic tank orc'e'sspool permitted if public sewer is.available within 200 feet.) Septic Tank: Distance.from nearest wei4-r-M.----Distance from foundation--f ---------Matekal---, _ _"--- ............. ofcompartments-. A 7 �� --- -No. Disposal Field: Distance from nearest well-A-699 Distance from foundati ---,��"------Distance to nearest lot line--3�-.--- �'^ Nur elr of lines_-_.--_1------ Length of each line--- -- "--- -- s-_-.-. � i - - Width of trench- ----------------------------- Type of filter material/- ._Depth of filter material-.-. --�---dotal length--- -- --------------------------- Seepage Pit: Distance to nearest well.---------------------Distance from foundation------_-----------.Distance to nearest lot line--_------.---..- ❑ Number of pits----------------------Lining material-----------------------Size: Diameter-----------------------.Depth--------------------------- ----- 'I y� t Cesspool: Distance from nearest well_________________Distance from foundation material-.-.---..."---.----.--..-----------.- ❑ Size: Diameter----- ------------------_---------Depth------------- -------- ------------------------ --Liquid Capacity----------------------------gals. 1. ill ------Distance from nearest buiidin Privy: Distance from nearest well----- ----------------- --- ----------------- 9------------------------------ ----------- 0 ElDistanceto nearest lot line-- ------------------------------------ -------------------------------------------------------------------------------------------------- .� ilf �ic/_._ sdT / 5 Remodel' and/or repairin (describe):---.--- ----- ------------ � ._ - °I� ----------------------------------------------------------------------------------------- - -ill I hereby certify that I`have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State laws, ani rules and regulations of the San Joaquin Local Health District. (Signed)------------------ "- --9� " L -l ---------------I�F Contractor) B . - ----- ----------- rile (Plot plan, showing size of-iot, location of cyst to relation to wells, buildings, etc., can be placed on reverse side). Nji I I� FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY--"C," """------- - ----------- -----------------------------t . DATE---�"�-------°------- ---------------------------- REVIEWED BY------------------ - -------- ------------- --------------------------------r-----. i' DATE_-------------------------------------------------------- .:f- BUILDINGPERMIT ISSUED------- ------ -------------------------------------------------------------------- --- t ,t`'` DATE------------------------------------------------------------- 1i Alterations and/or recommendations:---.------_ ' ------------------------------ ------------- ------------------------------------ •------------------------------------------•--•---------------- ----- ------ --- --------------------------------------------- -- --------- -------- , -------------!• -t------------------------------------------------------------------- i '------------------------------------------JM---------•------------------------------------ ------ -------------- ----------Q-/--F------------------------------------------ -- - ----------------------------- -------- -------------- ---------- -------------------------------------------- ---------- ------------- ----- - - ------ --------`------------------------------ ----------- ----------------------- FINAL INSPECTION f i c FINAL INSPECTION BY: ---- ------ Date----- ----------- -'---------- SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Hazelton Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,California Manteca,California Tracy,California