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FOR OFFICE USE: Rr� ..._--�._... ---------------------------------------- � l Q APPLICATION FOR SANITATION PERMIT Permit No. �...-�..%... -•---- (Complete in Duplicate) Z Date Issued ---------------------------------...................... This Permit.Exnires 1 Year From 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 aa in compliance;with County Ordinance No. 549. JOB ADDRESS AND L CATION--•-----�--`�--4?' I'll OB ---_----------............................ Owner's Name......... ...Qw.�.�D i.... _l__Li: R.N:�.��- •-•-------•-- Phone...........................-------- .r p Address................. ---------------------•-•-------- Y.........--.................................................... Contractor's Name..... �1 1 •--•-------.-.--•--•-----•---....-----•------------------------------------............ Phone... > r Installation Number of living units:nCe____ Numberof bedrooms _tment House I-] Commercial [:] Trailer Court ❑ Motel [3 Other ❑ __ Number of baths J.... Lot size .. ...x..Qp........................ Water Supply: Public system ❑ Community system ❑ Private Depth to Water Table ........ ft. t Character of soil to a depth of 3 feet: Send Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe❑ Hardpan ❑ Previous Application Made: (If yes,date____________________) No J New Construction Yes o ❑ FHA/VA: Yes,O' No ❑ ----TYPE-�OF-I NSTAL-LATION',AN D-SPECIFICATION (No sePttc ten or cesspool Pe,r.m..,in_ e~ iPu is rsewer is available wtt In 200 feet.) SepticTank: Distancem Distance from foundstion----/40_ ..........M t real_KE- >kQOD................ e __. ...No. of-compartm � _ f _ f �i . Disposal Field: Distance from nearessttt well-_�__..._Uiif�a � f�p�n �a ndafion._.1 .....'Dls#ante to nearest lot life.-. 1� k "7r Number of lines--.. ' _____________________ Len hof each me__ ._..___ ________,____ __.Width of trench.-_- __- 113 / y Type of filter material-� c i____Depth of filter material-___ - __-- - Total length-------f`.�� ...................... - == Seepage Pit: Distance to nearest well----------- ------Distance from foundation-----------_........Distance to nearest lot line----._______-_-_ 1 � ❑ Number of pits------------------Lining material--------...---•------:Size: Diameter----.------..-.--------.Depth--------------------------- Cesspool: -----Cess ool: Distance from nearest,v�ell-----------------Distance from foundation____________::____-.Lining material.._____--...___.____________________- 1n ❑ Size: Diameter....___ --------------•--..._-_Depth ------------------------------------------Liquid Capacity----------------------•-••--gals. Privy: Distance from nearest well--------------------- Distance from nearest building { ❑ —.,..,.� --1.1.. -i ., Distance to nearest-lot line--------•-•-------------� Remodeling and/or repairing (describe):--- 1 ; :NC it1l�f `I"f -irk---- T.-.. ...�Fl.M.urn=_.......... �-A�-=----------------- IS1 rte. .. �-.. p 1 , ' F 1 hereby certify that I have prepared this application-and-that-thework`will-be"done in accordance with San Joaquin County t ordinances, State laws, and r es and re gulation s of the!San Joaquin Local Health District. t I (Sig,)-,, -- - ------ __--------___ -- - -LOwn red -or.; ct d i By:....................................................................... ------------------------------------(Title) "` (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY:< APPLICATION ACCEPTED BY----- ---------------•------------------------------------------: ------ DATE-------c :'.. -' 'L��, �..---....----- REVIEWEDBY------------------------------------------------------------------------------------- -------------- ...............:........ DATE.........................................................•� # BUILDINGPERMIT ISSUED----------------------------------- _-----------------------------------------------------C------. DATE------------------------------------__----------{------- Alterations aVTM or recommend'ations:--/Q.nr-63---------LUVfifS---- FRT 1?----�--1 4}�_ .._.- ------------------------1 - `-:------------ ----- r l .........................................I..........-_._._...... ----.....-----•------------ ' " '-.------------------------------------------------ n. . . _. . �- _ .� _. _ - . _ - -� _ - --=- _.. . ...... = t ------- -------------------------------------------------•---..._._-----.---•--••-----•-•-- -T _ Y F FINAL INSPECTION - Dele_.. ------------------------------ _�"_ .. SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 114 Sycamore Street 205 West 9th Street Stockton,California Lodi,California Manteca,California Tracyr California EB 9 REVISED 8-99 RM 6-61 ATLAS - ~