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FOR OFFICE USE: ----------- ----------------- ----- Permit No. _ .... .P :D -- -----_--- - APPLICATION FOR SANITATION PERMIT ---------------------.- - _--.-- -..__. _. (Complete in Duplicate) Date Issues{ /iz�__--x-1.3-`P/__-_._-_--------.--. 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 in compliance with County Ordinance No. 549. JOB ADDRESS ANDLOCATION �'� '1 1�.�-R_?1K----� ------- 11�lAl�L` A Owner's Name-------R104191PW--------------- ----- Phone------------------------------------ Address.........1 --' .......010t.....rAjFl.M10/V77;-----------------M-`-1-�--'--------------------------------------------- •---------------------------....... Contractor's Name----01kW--K..'------ ------------ ---------------------------------------- - -----------•-- Phone................................... Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: __l.-_ Number of bedrooms 3--- Number of baths 2--- Lot size ---4CR-F 6-E-- -------•----•--•-------- Water Supply: Public system ❑ Community system ❑ -P-rivate;�epth to Water Table f- _ ft Character of soil to a depth of 3 feet- Sand � Gravel ❑ ;Sandy Learn❑ Clair-Loam-❑ Clay ❑ Adobe❑ Hardpan ❑ Previous Application Made: (If yes,date------ --- No 0----New Construction: Yes E�-No ❑ FHA/VA: Yes 2--No ❑ TYPE OF INSTALLATION AND SPECIFIGATlONS (No septic tank or cesspool permitted if public sewer is available wAin 200 feet.) .; d Septic T Distance from nearest well �t Distance from foundation......1Q.......Mate ial Cp/1PC 'T -_..____. No. of compartments_..__ --_____.. -.-Sae. . _ X--___-Liquid depth , '7--- Capacity_.._.�.�Q�__ Ir Disposal field: Distance from nearest well---. ...Distance from foundation..l_-0--------..Distance to nearest lot li�f`.?_.._...... 15, Number of lines--------2...r.............:..Length of each line_____T.?_.._.t._-..Width of trench_-_-_2 .___---------------- Type of filter materiaL_R-QCK-----Depth Q -filter-material----.n_---___-Total length--------- ---�___.- Seepage Pit: Distance to nearest well..._.----------------Distance, from foundation--------------------Distance to nearest lot line-------.--_____- ❑ Number of pits-----------------_-.Lining material------.--------------- Size: Diameter----------------------Depth-----.-._.-.----_._.-.-_---.-___ Cesspool: Distance from nearest well -. __.__Distance from foundation - ------------- -.Lining material--------------------------------- 171 Size: . --- -._ --__ --___-❑ Size: Diameter_ __ ____________ _ ___ - --.Depth--------------- ------- - -- -- - - ----Liquid_Capacity- --------- -------gals. _ Privy: Distance from"nearest well-----------------------------------------.-------Distance from nearest building_.__:----------------------------------_. ❑ Distance to nearest lot.line---------e-------- - ------------------------- ---•------------------------------------------------------- Remodeling and/or repairing (describe):------------------------------------------ -------------------------------------=------------------------ ---------------------------------------------- ------------------------- --------------------------------------------------------------------------------------------------------------------------------------- -------------------------------•------- 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, and rules and regulations of the San Joaquin Local Health District. w (Signed) = - ---- ---... -- y -- ---(Owner and/or Contractor) # ------------ By: ---- --- --- ----- - ------ ---- - -- --- ----- ._ (Plot plain,. s ing size of ot, location of system in relation to wells, buildings, etc., carr be`Placed-,oW'evers+e side). FOR DEPARTMWIZLD.NLY..- APPLICATION ACCEPTED BY--------- .R-.Q`----------------------------------------------------- -------------- DATE-------A-'_t? -o� e�_--------------- ------ REVIEWEDBY---------------------------------------------- ----------------------- ----------------------------------- ------------------ DATE----- ------------------------------------------------------ BUILDING PERMIT ISSUED-------- ----- -- ------------- :- ------------------------ _ ------- .. -- ._ DATE---------- ---- ---- -- --- - ------------------------- Alterations and/or recommendations:----------- ----------- -- --------- ----- ---- -------------------------- --------------------------------------------------•---------------- ---------- -- ----------------------------- - --- • ------•-•-----------•- - ----- - ----- FINAL INSPECTION BY: - Date----------------112----�- — 7------------ ------- -------- 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 E.H.9 2M 1.67 Vanguard Press