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hUKUf-HCE USE: --•----------------- ----------------- ----------------------- APPLICATION FOR SANITATION PERMIT Permit No. .Z,�?��..�1.1. --------- ----------- - - - (Complete in Duplicate) to- ---------- -� �- �"""" This Perrrlit'Ex fres"i YearFrtam'Date`Issued � Date Issued ......I...... :. f (a Application is hereby made to the Sen Joaquin Local Health District fora permit to construct and install the work herein described. This application is made in compliance_with County Ordinance No. 549. � r , JOB ADDRESS AND LOCATION•._:_�! F _ ,_ - „.--•_._ jn•�- -Q.--•_-----_ , ----------••--------------•-•------------••-•---- -••-•--•-----••--•-••••--•---••-- Owner's Name..•-- jn _� _...,.W.P..F R � `-$ -----------------------------•------------•---------------•----.- Phone_.A!0 1 Address-=-...41x .................................. Contractor's Name-------�_U.?-- -'--•-•-- -- -------•-- ----- - ----•------•-------- -- • •--••--------------- Phone................................... Installation will serve: Residence [�, Apartment House Commercial x , ❑ ❑ Trailer Court ❑ Motel ❑ Other Number of living units: __h..__ Number of bedrooms _� Number of baths ---I... Lot size -.71_Cz'_-?t-l•��' Water Supply: Public system ❑ Community system ❑ Private ® Depth to Water Table 40. ft. Character of soil to a depth of 3 feet: Sand [:] Gravel ❑ Sandy Loam ❑ Clay Loam El Clay E] Adobe ag Hardpan ❑ Previous Application Made: (If yes,date--------------------) No ffA New Construction: Yes J$ No ❑ FHA/VA: Yes ❑ No TYPE OF INSTALLATION AND SPECIFICATIONS. (No septic tank or cesspool permitted if public sewer is available within 200 feet.) } Septic Tank: Distance fromnearest well----------------- from foundation__...___.___.__ -.Material____............................................ No, of compartments_ Size.------••------------ ----------Liquid depth--•-----------------..__..Capacity._' 4 ------'-,u Disposal Field: Distance from nearest well..`-,S.°---_._Distance from foundation..'�Q-_....__Distance to nearest lot line...... ----. Number of lines---••---------•-------------------Length of each line-__..&- ..................Width of french...... ?r-4--`!----•----------- Type of filter_material._.toc,.h--------Depth of filter material_..-_1_$_"--------Total length.___... `.•_.--•---------- --- Seepage Pit: Distance to nearest well �'------Distance from foundation----ji-0-d_......Distance to nearest lot line-----45--1-._. ®• Number of pits--L_1-------------Lining material..:=n.c.A;.-------Size: Diameter.Q'-X_b!..----Depth......(of ._._...•_-............ Cesspool: i,.,Distance from nearest well_________________Distance from foundation---.-------------- Lining material.. ...---••---•- ❑ Size: Diameter --------------- ------Depth""'----•-----------------------------------------Liquid Capacity..---------•---------------.gals. ' Privy: Distance from.nearest well _`_.`---____._._ ___--.Distance from nearest building g---------••---•-----••-•------------------ ❑ Distance-to nearest lot line._.______._..:_________a_ l Remodeling and/or repairing (describe):----- ,�j-�-+ ,.trr p .. '-------------------• ----_-.. t:..._.._.__.:.-----_---..._ -------------- --•-------------- •----- I hereby certify thet I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State laws,'and r s and regulations--of-thee n Joaquin Local Health District. Signed).-d ¢ ( - s ..-: - -----_------••-------- ---------------••------------(Owner and/or Contractor) 1 / c or) By:--------•--------------------------------•-_...----...-------------•-----------�-------------•---- - --------.. Title - ---------------( )----•-----------------------•---- ... (Plot plan, showing size of lot, location of system-in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY I APPLICATION ACCEPTED BY ."` -------•----•--•----------- DATE..--- -�•` --!p.t--------- REVIEWED BY-----•- IS t-E -------------------- ---------------•----------• ---------------•--- DATE------------------ ---------' -----------•---- $UILDING PERMIT ISSUED. ---- --------- --------------------•----•-------------------- ---------•--------- DATE---- ------ r---------------- AFFeretions end/or recommendations:__.__________________ ”" '---"""'---' ------------------------------------•------ •=--- ! ---------------------------------------- •------------- ---------•------------•- � 1 FINAL INSPECTION:BY:.4-�°- --------------------- _ n �" �_ Date :lz-- --- ----------- -------- � s �, .r FYI rT :•� ----••--.. SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 west Oak Street 124 Sycamore Street Stockton,California20S West 9th Street t Lodi,California Manteca,California Tracy,California =M REVISED e•89 RM 3-81 ATLAS