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F R OFFICE USE: / LL - AFPS�ICATION --------- _ OR SANITATION PERMIT -t Perrni-'No. .:� . (Complete in Duplicate) 5 t 3_gg5 _S-_-fc!A-t-Et�.�n%d This Permit Expires 1 Year From Date Issued Date Issued ______ Applicatio(1-li-slhereby made to the San--Joaqu ri:�Local Health District fas a permit to construct and install the work herein described. This application-is-made-in-compliance"with-County•Ordinance-Ne--549--:., 22S"-1710"03 R I N i� JOB A DkESS-AND LOCATION-A- ,•' ( C v r: , !A- ---- ------- '---P---"----N---- ----------------------------- . } Owner's Name;; +� -----= °'x ''. '`� ; _ slr \ Phone Address_.................j r_e�..:...z =----- � --- -9--------' 1_P. � .; ----- ---- r / Contractor's'Name-------6_w_111: ��',.___--- ."--- ---` -- `'-- --- = ----- �--- Phone----••-•--------------------------- Installation will serve: Residence ❑ Apartment'HouSe'❑ Commercial ❑ Trailer Geer# Q Motel ❑ Other ❑ Number of 'loin units: .__.___ Number of. bedrooms _ N _ um6e of.�batbs—____ Lot size -- € -�:�__________________ --r Water Supply: Public system ❑ Community-system ❑ Private 12-'Depth to Water Table ft. Character of soil to a depth-of 3 feet:. Sand Gravel j], Sandy Loam ❑ Clay Lo�rn ❑ Clay ❑ Adobe ❑ Hardpan ❑ Previous Application Made,- (If yes,date;_- --------i J No New Construction: Yes °8No ❑ FHA/VA: Yes ❑ No ff", TYPE OF INSTALLATION,AND SPECIFICATIONS:' (No septic tank or cesspool perr4,ed if%pt)blic sewer 's available within 200 feelt-..)) Septic silk: Distance from neare4 wellrt� D' to"rice from foundation___ _.____ Mate.ial '--------------------------------- No'. " ` __-- No. of;compartments_.____.---2. _ 1 �f� 6 _Liquid depth _ 5___- _ Capacity___ `"{ Size Disposal Field: Distance from neares+.veli__ `"�'_ Distance from foundation___-�a...±__._.Distance to nearest lot line____------ Number __._ Nuber of lines each _.___._._.Width of trench-- .-- 6--- W�1 T;pe of filter material__ -C --------Depth of filter material___ Total length--- __ ---___-".---___.__ Seepage Pit: Dtistance to nearest well__--------------------Distance from fourldatiorz__Ki-C_. .___.Distance to nearest lot line__:____________._ ❑ 1Plumbe'r of pits----------------------Lining material--------....__________:Size: Diameter -------------------Deprth--------------------------------- Cesspool: Distance from nearest well----------------- from found ion.,.='..__._____--Lining material-------------------.__.___-________ 171 Size: Diameter------------------------ ___----Depth--------------------------------' ---------._._ It gals. Privy: Dista5ce from nearest well:.................... Distance from near'Liquid Capacity... esbuild'ing-= - ON ❑ Distance to nearest lot line--------------- - f �. Remodeling and/or rePsring ----- ---__ ._ — - ` r ________ -i --------------------------------._: N --------------------------------------------------------------------- __,__---_---_-.__-___--_--.--___________---_--"----_____---___...._.._____.____.._.__...___.--- I hereby certify thaF Ij have prepared this applica+ion and that the woik.will be-done in accordance with San Joaquin Counfy ordinances, State laws,.4.nd rules and regulations of'the San Joaquin Local Health District. C Signed) ., --------- --------------- -------- -----. Owner and/or Con+ractor By: - ---_ - ------------------------'� ----------------------- --- - -- -------------- ---------1? I (Plot plan, showing s-i}"ej.of, lot;Potation of system in relation to wells, buildings, etc., can be placed on reverse side).. r FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED 17 D BY- ------------------------- ___ DATE----------------------------------------------------- ' ' ° '-6 ' € REVIEWED BY ' �' l -------------- ------------------------------------- DATE------------------------------------ - ------------ = ' BUILDING PERMIT ISSUED ------ ---- - ---------------- =" - DATE - i Alterations and/or aecomme da+ions:-- ��-?1-�- -\ --- �Q--�`Z±v�. `�� - '-- -------- '----- --`-S`-- �l--'----' ' - F �� `---moo.e� 6'�e 0 1C 1,2'eo ti FINAL NS CTION BY:- ---------------------------------- Date_ - : ---------------------- I 0_ ::i-4/Z --- SAN JOAQUIN LOCAL HEALTH DISTRICT 1801 E.Hazellon Ave. 300 West Oak Street W124 Sycamore Street. 205 West 9th Street Stockton,California Lodi,California! ''* Manteca,California' Tracy,California r F.p.eo.