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FOR OFFICE USE; gr� ------ ------ APPLICATION 1=0R.�SANITATION _PERMIT Permit No. - (Complete in Duplicate) 1 Date Issued -------------- --- ------ -------- This Permit Expires 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 made in compliance with County Ordinance No. 549. -------------- ? r ION ------t--�----------•---------------------------JOBAD RESS AND LOC = xs" ------------ ------ Phone------------------------------------ Owner's - e -- - s _.; Address -• ------------ T F c�-& j rel �,* 1' - I /-------------------- - - - ---------. honel( ------- � Contractor's Name---------------------------------•--•---------•--••----••----- - ---------------------------------- - Installation will sar e: Residence�Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ ,Other ❑ Number of living units: _),_"Number of bedrooms J. Number of baths —Lot size ------- -- _--t�---c�' ---- Water Supply: Public system ❑ Community system ❑ Private , Depth to!Water Tablea/ .- ft.I Character of soil to a depth oft3 fest: Sand ❑ Graver ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ AdobHardpan E] Previous Application Made: ff yes date------- -----------) No❑ New Construction: Yes [:1, IN SHA/VA: Yes E] N TYPE OF INSTALLATION AND SPECIFICATIONS: 4 ( P '! p permitted if public sewer is av)eifabl it in 200 feet.) Septic aokst tic tank esfroml nearest well .. ......Disf6 4411 dation.. --�..--.-__..MateriaC( tw` ' V f° ( No. of compartments......... 2-- •- -- --- --- -- -----Liquid depth-------- --I L Capacity--. ---- Disposal Field- Distance from nearest well .-__---Distance from' foundation on------.__---------Di ante to nearest lot line................. i j Number of lines-------- ✓ ----------------Length of each line 6 4_ yr . _-Width of trench.... __- __._---------_-- Type of filter iatenal--__-_ ._-..._Depth of filter material..-. _- ....- Totel length..-..- d.......................... �> t. Seepage Pit: Distance to nearest well-----------------;Distance from foundation------.-------------Distance to nearest lot line----------------. -� Dept Number ofpits :t*---Linrrmg material----'�---:---- - -.-size: Diameter---------------- C� t Cesspool: ,Distance fiom nearest well--_- __.-,- _,Di"stance from foundatjon..._.....-.._.....Lining material__---------------------------------. ( ❑ Size: Diameter!------------- 7Nrn--]Death------------------------------ -------------- ------Liquid Capacity----------------------------gals. % } "V Privy: Distance from,rearest well---- ----------....___-------------------------Distance from nearest building....-_____.------------.....--___..-.----. ❑ - Distance.to nearest lot line----- ------------f- ----------------- ------------ ------------------------------------------------------- --------------- I ' -- - 'Pl__4 -------- ---------1 �5' t� ----------------- Remodeling and/or repairing(describe): _-..... r __� b _,'--.- .:. : ��` __,f 4Z#,C------------ c ------------ U-Etf� ------ �... s ------------------------- ------------- ---- L------------------------------------------ ------------------ ------------------------ -/ y �I ------------------------------------------------------ --ere - - - e c # •'Local Health Dtstrlct. I hereby certify that I have prepared this application aand n Joaaulnhe work will be done.tn accordance with San Joaquin Count ordinances, S laws, and rules and regulations of the S q I ( - ------------- - f--------- Si ned --------- (Signed)---- {Owner and/or Contractor { 9 )--- r' ' --------------- - - .. howtn size of lot lot ---------------- - --- ------------------------ -- -------- {Title) (Plot plan, s g location of system in relation to wells, buildings, etc., can be placed on reverse side). rr +4 R DEPARTMENT USE,ONLY �/ APPLICATION ACCEPTED BY----; ---- -- ------------------------------------------------ DATE ��%f�/� ----- - -------------------- REVIEWEDBY----------------------------------'--- ------------•---- ----------------------------------- ---------------- DATE + DATE------------------------------------------------------------- ......................... PERMIT ISSUED----- ------------------------------------------------------------------------------------ 4. . 4 Alterations and[or rec mendat' s:'-------- -------------- ----------------- --�---- --------------- ry ----- - --t �V�-- 3� �' A4---------- YOB`�L'A_ a tet, - - ; p �.. ,`�--• --AVISf�� - o- -- -- - - e- ---- -- � ----------�- - ------- - ss ------S�i -:,-.,- is -- , �Qt -- a f9 �-�----------- ---------- -- - .-- r - -- ------------- 1------=-=--- - k I - -0�-'t'S•r--- --�7r`r -✓,Yf�-f-:----- t---------- - --- ------------------ --- -+-'7- - ' &07- , o- 1 r FINALINSPECTION BY----------YJ-- - -- ----•----- ---------- Date---------------------------- --- ---- - - -------------------------------------- I # SAN JOAQUIN LOCAL HEALTH DISTRICT 1641 E.Masellon Me. 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California s Lodi,California Manteca,California Tracy,California