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FOR OFFICE USE- ------- ---- -- �. ---- .. ________________________________________________________ 1 APPLICATION FOR SANITATION PERMIT Permit No. . .. .,! z --------- ----------------------------------------------- (Complete in Duplicate) �J --- --- --------------------------------------------- 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.549. I JOB ADDRESS AND LOCATION------_------------ _ _ --- ' ._ ° LJ1 y Owner's Name........................ . . .... 6 .. ::.---� \ -- - - ----- --- - - - Phon �,1 Address-........-•---•----•-....-•-• / ,� rR' pi . ...... .__...... - ... Y--------------- -----------�;,;�........._..-._---.--•-_ -•--------- __.1.•---_-------__----_.-_-_-_.-_-_.---- :. X Contractor's Name.........._ � r'k ��-"� �� - �:-37�ne...._._...._ Installation will serve: Residence Apartment House ❑ Commercial ❑ '�Tr ;Court0 Motel ❑ Other ❑ ?3 Number of living units: . Number of bedrooms;�.-'-. Number of baths- ..... Lot size 1T4_AO_.-_ t � �: Water Supply: Public system ❑ Community system ❑ Private °!'Depthto,Water Tablf ft.- Character of soil to a depth of 3 feet: Send Gravel Sand il_am ? y� .� Clay ❑ Adobe❑ Ha ❑ P ❑ ❑ y ❑�.Cla Loam t Previous Application Made: (if yes,date____________________l No ❑ New,Construction:;Yes -No_❑_PHA/VA: Yes ❑ No� TYPE OF INSTALLATION AND SPECIFICATIONS: - ( P p p public wer is available within 00 feet. P — T w. r w �o septic tank or cesspool ermined if u �e�� ` T � - � . : _ t lit Septic Tank; Distance from nearest we ___ ,Dist fromil._�X_�O�Linquicl und ' -- - -----------.Materit`i__ •i9--�.. NA I No of compartments__ _______). ____Size- ��_ de th_--_.___ __________iCapaci }�--� Disposal Field: Distance from neares well__57- -4"�-bista ce from foundation.-.M. Distance to nearest Igtilin .l�- Number of lines----,_ [ I r 1 ength of each line------ 1 �{� Width of trench.___ Type of filter material._ � ._.�._-- Depth of filter material.../_'?------------ length______.. _4� ...._.__. ---- Seepage Pit: Distance to nearest ell ;-� _-_:Distalf c-e fr m fou ation__/Q--.......__..Distance�to nearest lot ine__..�_..__.. Nur bar of pits__..11 ;�--E#.__Lining material ) rX/KSize: Diameter__.... Depth----- --_-._____ Cess Cesspool: Distance from nearest w p a est ell-----------------Distance from foundation-------------------.Lining material_.__:................................ ❑ Size: Diameter----I-----------------•-------------Depth-------------- •------------------ Liquid Capacity-/r gals. c Privy: Distance from nearest well_________________________.________._______-_____Distance from nearest building.__._=��._-_-______. ❑ Distance to nearest lot line----------------------------------------------------------------------- •-------•---- r• .. V i ---------_--- -------------- m � Remodeling and/or repairing (describe):-•----------_---------• ----------------------•---------•------•-••-•------•-•--------•-•------I .--------•----- i{ t ! 1 ---•------ -- •---------•-- ---- I---------------•---_-=T-•-•---------•-------------------•--•-------•-------••-•-----------------------------------•--- = •-..-------........ I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County } ordinances, State laws, and rules and're lotion of the San Joaquin Local Health District. i (Signed)-----Y-1". --� -- ----------- - ---------------- -------------------------------(owner and/or Contractor) BY�--=------------•---•-�--- ==-------------------•-•------•-•-=-=---=-------------------=:.-• ---- ----------------------={Title}.=-_-:....::._:.--�-- -- - --,�;,,-.. 9-= ai �"`—(Plot plan;showing`size of-lot Vocation of systern in relation to-w uildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY--------- ---------------------_------ a--------- -•- - .L-_-' DATE----- / ----------- ir REVIEWED BY__.. ------------------------4--------------------------------------•-----•--------- ----------•--•-•------- DATE-------•--- BUILDING PERMIT ISSUED------------------------------------------------------------------------------------------------ DAT E---------------•------ Alterations end/or reco`mmencfations:__ ,,._...;.._,._,.___.__, _._:_. i ---------•----------•-----•------- ---•-•----•- ------------------• --------------------------------------- -----•---•-------------•---------------- ` =: `` „`------ -----•-•--------••-----••-•-------• ....................................... ----••--- -------•------------------------•-------------------•-------•=#--I------------••-------------- ----- ---�`` - ••----- ............................................... - --'-- ---- ____ ,pry ._z__.___ _..__-•__•----------------•--_-----...._. -----___�__.._.-_ .a% ------------------------ Yt� ---•_'_ ___.____..._._•-_____.________•_._ -_•_____ -----------..---------------------•-------. fp FINALINSPECTION BY----------------- - --------------------------------------------- Date---- ----------------- --------------------------------- ---------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 Soath American Street 300 West Oak Street 124 Sycamore Street 205 West 91h Street Stockton,California Lodi,California .� Manteca,California Tracy,California EB 9 REVISED 8-99 2M 6-61 ATLAS