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�APPLICATION FOR. SANITATION PERMIT Permit No. . (Complete�in,Duplicate)4'.4rc C�j rte• '� ` I Date Issued �O A173 Appli r io es hereby made'to the Sa�`Joaquin'Local Health Distctij fcar am +to construct ands install th work herein dscribed. r i F , Thu applic tion is `made in cdmpliance with County Or�inanceJ�-" 549:.- r J B A�RDRES'S AN LOCATION =_ _4 + �� : ^'''` y ,- Qwner's Name ._� ^ t3. Pha i # ---- ne.__s � S #• �. /�� Addres ..._lLl�_ fS`�3 .4,� •__4��ta-tr3�- T "�' ------------------------------------------- J Name______ .. _ .:_ 1 - � Ph ane_.__. Installa+in will'3 ' '� * ' iRes�dehce, partment House ❑ Commercial Trailer Court N` .�� a ❑� ❑ Motel ❑ Other ❑ WaterIN S ! : e r /! mber,o. iving``°unifs: "_:_,F�� r�of bedrooms 1_ Number af.beffist side ----- ___.4` 14 - \1$` -----_ ppy Public ysfem [a]: ''Co �i �yiystem 0 Private [ Doh Water TabtJ I Charac+� of JWJ6 a depth of 3 fe4 } and Grav I ❑ Sandy Loam Clay Loam ❑ Clay Adobe Hard { 'k, 1 t7 Y ❑ ❑ pan C4 Previous kpplicafion Made: Yes ❑ No sr ,New Construction: Yes No ❑ TYPE 4, INSTALLAT N.�•ND SPECIFICATIONS: _ i o sap#ic +ank or cesspo�laperrni+ted if publiF cs vier is available within 200 feet.] Septi ------------ c`T;15'�d } Distanca #r e r�st�w l=�4 - --------_Disfanceufrom oundafiian__-, d---_- , ,. �II Ma.ter�al--- ''---- o.lf c r �n s: - _Sed X ----Liquid depth--- Capacity f `�Disposa : Distance fromriaesoyde 1. 6. DEstance from foundation__-- �' -------_.Distance to nearest lot lin •____ --� Number dF. Imes________ �.-___ _ _-- _ en th of each line_- r # ro g - +��--;----.Width of tre ch. r2- ; Type of f�lfer mate' i�l_._ _ �c- ----Depth of filter material-----� - Total length- ____• - - -------------I Seepage Pit: Distance to nearest well____________---_-----DisLnc�""frdt On�at`�io �_�- _ Distance to n crest lot line-_________.______ I i ❑ Number of pits ------Lining mafierial--------- ---- S' Diameter-- D ptn o ------ Cesspool: Distance from near esf ei o- --- 6-6if"' A I }ounfaf o'n-}:-�3-_I�_- Lining materral-------------- -------------------- ❑ Size. Diameter---------------------------- " --- Depth---A t -�'y --------Liquid CapaiitY '----------- -----------gals. i Privy: Distance from nearest well __V f! ce4'trom nearest building_ .__-__---___--- ❑ ----------- Distance to nearest lot line....... - -------------- ,. s Remodeling_and/or--repairing describe) -- w� r --ql i -vn_ - ------- --------------- =— ---------------'-------------------------------- ------ _ y —I"hereby-certify tha !'heye re ar ordinances, S a+e,laws, and rules latioaspf�ihe Sart Joaquinat hLacal HealltheDisfrict �danceth San Joaquin Count; (Signed) q---------- - ---------------- - ----- - ------------------------------------------------ --------------------------to ner &0011�4+ I By----------------------------------------- ____-.Tale ot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). 1 01 FOR DEPARTMENT USE NLY t APPLICATION ACCEPTED BY----- - ---- ---_ ' ,r ------------- DATES --- ---- REVIEWED BY _ ------------------------------------------------------ DATE-----''' -' -i i BUILDING PERMIT ISSUED----------------- ----------------------------- i -- ----------------------------------------------t ----------- DATE------ Alfera ion and/or recommendations:____-.____ _ r --------------------- --- 7 6 �- 4 -----X ` - .-l__v-- ..Of �------------------- -------- - --------- ---- --------------------- � ` , 11 I FINAL INSPECTION BY------------------------------------ ------------ Date-'-'- i. - SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American StreetL '�� i 300 West Oak Street 132 Sycamore Street 814 North "C" Street Stockton, Celi�ornie qr, "" Lodi, California Tracy. California Manteca, California E5-4-2M X0.52 Revised W-2100 w �, +' 4 • o. ` i�