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FOR OFFICE USE: ------------------------------- APPLICATION FOR SANITATION PERMIT Permit No. ------------- ----------- ,11�?... ?... ------------------------- ---------------- ----------- (Complete in Duplicate){ p p� ) Date Issued ------------------------------------------------------- ... I 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 iiss�m_ade_in_compliance�with County Ordinance No. 549. - r JOB ADDRESS AND LOCATION.- !'y ± ' ' "''t'f/`' Cf"e °�G -------------------- Owner's ------------------Owner's.-Name = e = - Phone W .----••-------_-•-............ - -•-••- Address ....f�� j ...• �r - ------------------------------------••-•--•----------•---�''`-4e-�/ Contractor's_Name......... ... .... -'-.:..:... o otel one Other s Installation will serve. • Residence ,[ Aprment House ❑ Commercial ❑ Troller Court ❑ ❑ ❑ Number of living units: __h�umber of bedrooms x2- Number of baths Lot size ..... . Water Supply: s ❑Publicstem 0 Communit4 system Private P< Depth to Water Table 4A. ft. t�Y Y Y �'. P � Character of soil to a depth of 3 feet:. Sand ElGravel ❑� Sandy Loam X- Clay Loam ElClay ❑ Adobe❑ HardpIan ❑ r i Previous Application Mader Ilf yes,date_______________ _`) NoA New Construction: Yes No ❑ FHANA: Yes ® No TYPE OF INSTALLATION AND SPECIFICATIONS {No septic tank or cesspool permitted if public sewer--is available within 200 feet.) Septic Tank: ...Distance from nearest well---jg_jO.--_-Distance � fro foundation----L&---------_Mate al ____0___�--: . ....... No. of com artments_- .__._Size O Liquid depth_ ____ Capacity .0!-0...... Disposal Field: Distance from nearest well.-.. --------Distance from foundation.___- Distance to nearest lot line----.Ir... Number ofdlines.... -------- ----- -- g -GO----Total length--------__.IFI..Q.-_-!_ I------ --- Length of each line___."'. _�.?...Wldth of trench_____ . Type of filter material �..�Depth of filter material___r�-.._ . �f' Distance to nearest lot line.... Seepage Pit: � `Distance to nearest well-----I- _____----Distance from fo nd ti n__ _--___/--_. .- ♦s Number of pits_-__-/______.______Lining material_ S ° ameter------�_�----- Depth____�.5_---- _________ Cesspool: Distance from nearest well_________________Distance from J6unclation-------------------.Lining material........... ju Size: Diameter---------------------- --------------Depth--•---------------------------------------------.._Liquid Capacity..-. - - ----�_._Distance from nearest buildinistance fromnearest well------------------------------------------- g•--•----- ----------�-------Distance to nearest lot line-------------•--•------•-------------------------------------•-•----•---------------------------------------•---------------------'Remodeling and/or repairing (describe)_____________________.._---------------------•----_._._---------------------•.-------------•-•------------•------•--------------------. ----------•--------------------•---------------_-------•---•--------------•----------------------- her --5 y P P g 1'P q q-------- ----------- - ------- --•-•-•--------------• ------ ----- --- --- ---------------- -------------•------- I hereb certif that I have re orad this a lira#ion and that the work wiN be done in accordance with Sen.Joe uin C ordinances, tate laws,, r es and regulations of the San Joaquin Local Health District. --------- --' ---------------------------- (Signed) { �ors.Contractor] --------•--•-•------ , Ys --------------------------------------- ------ -. .. F! --------------{Title}---- 40 ` ----------- (Plot plan, showing size of lot, location of syste -4 relation to wells, buildings, etc., can be placed on reverse side). e FOR DEPARTMENT USE ONLY APPLICATIONACCEPTED BY--- ----------------------- •-----------------------------------------•----------•---------------- DATE----------------------------------------------="------------ REVIEWEDBY........... -------•------------------------------------------ DATE-------� �� ,;; ----n�i------------ BUILDING PERMIT ISSUED------------------------------------------ DATE Alterationsand/or recommend'ations----------------------------------------------•---- -••--•------------•-------------------------•-•-----------•--------------••----------------•-----------.- -------------------------------•---. .._. �I I -' ----•-•---- - ----- ------------------- ---•-- ...... --.....- FINALiiNSPECTION BY:. ----- ----- -- - Date--------- -------- . . SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak street 124 Sycomas Street 205 West 9th Street Stockton,California Lodi,California Manteca,California Tracy,California ES 9 REVISED 5-99 2M 6^61 ATLAS