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1-UKUrri , USE- ....".. I APPLICATION FOR SANITATION PERMIT Pert4, No. ----- �-r.�� i (Complete in Duplicate) _ --- ------- ----------------------- --- ------------ --- this Permit Expires 1 Year From Date Issued 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. 449. r rr e , JOB ADDRESS AND LOCATION.._-_ �-" "",c �._"""" �^^— ph 1 Owner's Name._._. G, _..-- . .. "-•-- - - t - - one--- -a....4��_�.�I_'_.7 Address----- +�-�---------c�-••�------- F •----------------•------•-----------------•-•-------•-••---------------._............................................... Contractor's Name....jpejjLkjg1 ! _ t - - --- ----------•---•.........................................•-........ Phone-----...._....-•--•-••-----•-•----- Installation will serve: Residence gr Apartment House ❑ Commercial Trailer Court i t ❑ ❑ Motel Other ❑ Numberiof,.living units: -"!.__- Number of bedrooms -_5- Number of baths __".._._ Lot size ....... ..... . Water Supply: Public #ysfennJX Community system ❑ Private ❑ Depth to Water Table .5_1� ft. Character of soil to a depth of`3.;feet:, Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay [I Adobe Rr-Hardpan C) Previous Application Made: (If yes date_._ -----) No ❑ New Construction: Yes Q No ❑ FHA/VA: Yes ❑ No ❑ TYPE OF INSTALLATION,AND,SPECIFICATIONS: {No septic tank or cesspool permitted if;public sewer jis available within 200 feet.) D om'`. - ,.. ... ......... p- h- Septic Tank: Distance f ormnearest well. ;_.__ Istancerfromfoundation...... .......... .Material...-..-_.,.._....,..._. ❑ No. of compartments Size Liquid depth"....'"-- -.'Ca aci Disposal Field: Distance from nearest well-. -:Distanceifrom foundation_._.1.�....-....Distania to nsarast lot line... �W "' - ,® Number of lines_._.:.......-� - Length of eIra�cH'I, r dr ne_ -_ 0�/ti/iolfik+of r' Type`ofsfilter,moferial..:�e.iC------Depth of filter m6terial---W7'_1 'v-"""--Total length._ ... _"""_ :0 SeJR Number of Its...-_-- p .../-Linih material...._ ativn----/.�?.�____._.Q stance to nearest lot line------ y_-�..- I Seepage Pit: Distance to nearest well_"..��-""_Distance �r�omOf��Size: Diamet !f:""_-.pepth_..."�� Cesspool: Distance from nearest well--------------._Distanc"e from foundation..:..........._.._-.Lining material..-------_-.-_. ' Size: Diameter------------------ -----------I------Depth----•------------"--=----------- --------In---Liquid Capacity.............------------...gals. Privy: Distance from nearest well ......... ------.----..............---------- .-Distance fromearest buildin I g.._...--------------•---•-•--•--•--------- ❑ Distance to nearest lot cine -�}--------•-•- - -•- I - --------•------------=•--------------------------------------- Remodeling -...------•"-------- -- it Remodeling and/or repairing (describe):...._-.--- -------•-------------------------• ' ................................. ..----•--•----•-•--• -----• - F - .-------------','--,.-...----- -=-e— - .-. -----__._ .......-...____.r .------------------• -------I----...-----I------ ---------------------••-•••---....._. ----• _ = = _ I I [ ------ --------•-----------•-------------- ---------•-•-•---•----------•------------------•••-----•-----•--•- I hereby certify--fKa-+"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. (Signed)-------------------- ... ( an Contractor) ----- ------- --•-----'--% ----- Owner dor ontractor BYX----- �' - Title - I (Piot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). N a FOR DEPARTMENT USE ONLY i APPLICATION ACCEPTED BY------ e---- DATE----1" -----�.�--- --- - -------------------------------------- REVIEWEDBY ----- "--- -- --- ------------------------------------------------------------------------ DATE- BUILDING PERMIT ISSUED_ - t--------------------------------- -- ----------------- Alterations and/or re orrvjmen ationF--------------------- D --•---------------------------------- A• E __ �Q .��. ---r----------------------------•c -- •-- - --• -- -- . . . . . ---•---- T!`` - #&---•------- --------------- ---------------------------------------- -- ----- --- ------------------------------------------- FINAL INSPECTION Date...... l- - .".. { SAN JOAQUIN LOCAL HEALTH DISTRICT ,11= 4 Sycamore Street American Street 300 West Oak Street 12 205 West 9th Street t5loeklon,California Lodi,California Manteca,California Tracy,California [6 9 REVISED 8-99 YM B-61 ATLAS