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FOR OFFICE USE: APPLICATION `FOR` SANITATION PERMIT '-,- Permit No. q__3-,:-57 ----------------- ------ ---------------------- (Complete in Duplicate) e .. .. .�.. a Date.lssued --..-----_------------------------------- . ..'This Permit Expires'I'Year From Date'lssued Application is hereby made to the San Joaquin Local Health District for a permit to constr ct and install to work herein describ d. This application is made in compliance with County Ordinance No. 549. � � I/ �� JOB ADDRESS AND L A N____ �. _ 1 4 00-1, '--------------------- ----------�------_-------- Owner s Name----��`i ci- '�� =Q----------------------------- --- Phone__ 9 Q Address - I ---------------------------------------- = — '" `------------ Contractor's Nam __ _.. 1 Q _j� •------------------- on :.. ------------ Contractor's will serve: Residence partment House ❑ Commercial ❑ T /i er Court ❑ Motel ❑ Other ❑ Number of living units: .".._ Number of bed oorr --- Number of baths _!-_§- Lot size ______ __________ ____ ----..-.._ Water Supply: Public system ❑ Community system ❑ ':Private epth to Wafer Table V Character of soil to a depth of 3 feet: Sand [] Gravel ❑ Sandy Loam ❑ Clay Loam lay [❑ Ad be E] Hardpan ❑ ' Previous Application Made: -Ilf yes,date-.------..._-----.}„No'[] New Construction: Yes ❑ No HA/VA: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS:.” ,I ,, „4 p , r t r Vo septic tank oricesspool permitted if public sewer is available within 200 feet.) tic Ta nce, from nearest well__.__._'___._..___Distance from foundation--- ------------- Material_-----_--.-.._---..--_---_--_----.__._...__. -}, of compartments------------- --- ,l_size--------------------------------Liquid depth--------------------------Capacity-- .- s Di 7j1t; Distancefrom nearest well �___- Distance from foundation_ ._..__Distance to nearest lot line___.k umber of lines____ r� __ ___? _Length of each line.._ {` CWidth of trench �rype of filter material_.___..:- __Depth of filter maferiaL" __.-....___.Total length_______________ __�]__.. ._-_____ 1 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 , . material- -.---_;�.-:--_----._.__.----.-_--. ❑ Size: Diameter-------------------- --- - ----------Depth-------" ---------------------------��-------.-------Liquid Capacity-..... :_. {- - - Privy: Distance from nearest well--_,---_._-_-. _ -I --------------------Distance from inearest bui;ding------------- .:_ ___ ❑ Distance to nearest lot line.....-..--__._.--- I -------------------------- -------------------}--- ----------------------------------------- ---=-=-------------------- _4 Remodeling and/or repairing (describe):---------------------------- ---------- ------•----------------------------------------- -------------- ---•---------------------------------------- ------------------------------------------------ --- ---------- --- -------------- ------------- ------- ------------ --------------------------------- --- ---------------- ------------------------------------------------------------------------- ----- -- ------ -- --- ----------------------- -------- ----------------------------------- --------------- ----------------------------- ---------------- - ----------------------------------------------------- -- ------------------ ---------------------------------------------------------------------------"------------------------------- I hereby certify that�ve prepared t • application that the work will be done in accordance with San Joaquin County ordinances, State laws, a nn les and u ations of the an oaquin Local Health District. Signed �arf U + E --- --------------------- -- -- ------- ------ - ----------------------------------. � ontractorl 4 (Signed) SERViGE - 2915 E Winer Avta. HQ..f-6&41 rtl' ------ .--..." ---------- " B E.y---------------------------- - 4 (Plot plan, showing size of lot, location of system in rela i to we s, ildings, , can be placed on reverse side). f FOR-DEPARTMENT USE O Y a APPLICATION ACCEPTED IBY_:'._- _ -- `- ---t ------------------------------------------- DATE------ -------------A, ---------------- REVIEWEDBY------------------------------------ -0------------------------------------ ---------------------------------------------- DATE------ -------- "------------------ ---------•--------- BUILDINGPERMIT ISSUED;------------- --------------------------------------------------------------------------------------- DATE----:----- ------------------------------------ Alterationsand/or recommendations:---------------------- ----------- ------------------------------------------------------------------•------------------------------------------------------- ---------- ---------------------------------------------------------- =------- ------ -------------------------------------------------------------------------------------------------------- ---------------- ------- ---------------- -------------------- ---------- ------- ---------------------------------------- -------- -- -------------- -------------------------------- ---- - -------- ---- ------- -------- FINAL INSPECTION BY::r, ° . ---------- Qate f` � �2....--- ---"-"-"--"-"----" SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Hazeltan Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,California Manteca,California Tracy,California F.R.C{].