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APPLICATION FOR SANITATION PERMIT Permit No. (Complete in Duplicate) Date Issued __{V Applica+ion is hereby made to the San Joaquin Local Health District for a permit to construct and install t prkLe�re�in described. This application ii-s_maadej in compliance with County Ordinance No. 549. Y .Ew-'_4- �) ® f J B ADDRESS ANQ ATION ,-.x- ----.� -- -- �12�,wy F�eLC7'7�✓ ._- ----'l'----'-". ------------------------------- - -/ E Owner's Nam _ jj �� -"---------------- Phone--------- •- ------------------ Address - .. --- - '" -------•---------------------------------------------- --- ----- Contractor�s Name--- f `�-r-�'--------------`� i 1 ,O (rte._- Phone - Installation will serve: Residence ❑ Apartment House ❑ Commercial ❑ Trailer Court Motel ❑ Other ❑ Number of living units: 7PN mu ber of bedrooms --_YNumber of baths .0��Lot size ------/ --_-------- Water Supply: Public system ❑ Community system Private ❑ Depth to Water Tablea9ft.f Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam 2"Clay Loam ❑ Clay ❑ Adobe❑ Hardpan ❑ Previous Application Made: Yes ❑ No ❑ New Construction: Yes ❑ No TYPE OF INSTALLATION AND SPECIFICATIONS: (Noseptic tank or cesspool permitted if public sewer is available within 200 feet.) nZ, a k: Distance from nearest well--_----_----_-_-Distance from foundation-------------------.Material-----_.-.._..___--.---.---_.--------.-----.------ No. of compartments-------------- ----- -----Size--------------------------------Liquid depth--------- ----------------Capacity---------- -------- osal eld- Distance from nearest well_________________Distance from foundation------.---___-_-.._Distance to nearest lot line----------------- Number of lines-----------------------------------Length of each line---.---------..............--.Width of french----------------------------------- Type of filter material-------------------------Depth of filter material--------._.------------Total length------------------------------------------ Seepage Pit: Distance to nearest wall _ bistanc o fowdat.ion-��--�--------.�Disft�nce to nearest lot line-_/-J--_-.-_ Number of pits---- -----------------Lining material ,3-_-------Size: Diameter-_ -.--..-.--Depth_c �f Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material-_-._--__--_-.-._-'--------_._._. ❑ Size: Diameter----- ----------------------- : Depth-------------- -------------- -----------------Liquid Capacity-.-.--------------------_-.gals. Privy: Distance from nearest well---------------------------.-------------------.-Distance from nearest building--_--_--__-_-_-----.---___ --------------- ❑ Distance to nearest lot line------ -----------------------------------------•---------------------------------------------------------------- ---------------------------- d it n � _ - ---- '`delin nd/or repair g (d sct �= ` ------ ---- .._-------------- Remo Alt ----------- - ... _. ----. - _-------- ------------------------ -------- - ---------- -------------------------------------------- ----------------------------------------------------------------------------•----------------------------------------------------------- ----- ..----- I hereby certify that-1 have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State laws, and rules and regulations of the San aquin Local Health District. (Signed)--- DAY_ &WOW -- ----- - ------ -------- ontractor) Segific Tarok Service By:.- T Q� o.- ora ---140-2-704 ---- ---- ----- ---------- (Title) ------ (Plot plan, sh0WI g size of lot, Waffdmigf�!�tfm in reat'd towe 4buildings, et ., can be placed on reverse side). I FOR IPARTMENT USE ONLY - - I APPLICATION ACCEPTED BY--------------------- ----------------------------------- --------- DATE------------- LTi'- eJ ----- REVIEWED' BY- ----------- -- ----- ------------ - DATE = ---------- ----------------- BUILDING - ----•------------ BUILDINGPERMIT ISSUED------------------------------ - --------------------- ------------------------------------------- DATE... ----•--...-.------------------------- ------------------ Alterations --• -- - Alterationsand/or recommendations---------------------------------------------------------------------------------------------------------------------------------------------- ---------•-------- -•---------------------•-------------------------------------------- ----------------- ------------------------------------- -----------------•--------------------------------------------------------------------------- --------------------------------------••- -- •--------------- ---------------- ------------------------------------ •-----------------...-...----------------------------•-•-•---•----------------------•------------------I I = ---- ------ -------------------------- ------------------------------ --------------------------------- - -------------------------------------------------------•--- ----- FINAL INSPECTION BY:--- ----"`� P'`� � Date// - ------------------------------- ------------------------ SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Street 814 North "C1 Street Stockton, California Lodi, California Manteca, California Tracy, California ES--9 145446 ATWOOO