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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT Permit No. ..1.. (Complete in Duplicate) __________________________________________________________ This Permit Expires 1 Year From Date Issued Date Issued .��r�_....�.... Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein descn ed. This application is made in compliance with County Ordinance No. 549. 1 PPS JOB ADDRESS AND LOCATION__ ¢ rel. _- = .Z.F. =i ,�=.....- -= _ - — - Phone.-u_........................... O_wner�s_Name- _----- - Address-------------- �� EI:-" ,-"-....... -�-1 ! 4 -------------- ------------ ---------- _' Contractor's Name---------- R U rY4"�-_S------ T1�----- R K--- �� '......... Phone------; :--"""""-""....... Installation will serve: Residence O/Apartment House [-] Commercial [I Trailer Court ❑ M tel E] . Other [] Number of living units: --I----- Number of bedrooms 3--- Number baths Lot size __"•______________ Water Supply: Public system ❑ Community syst ❑ Private Depth to Weter Table�'��ft. Character of soil to a depth of 3 feet: Sand Gravel ❑ Sa Loam C] Clay Loa m'❑ lay ❑ Adobe C] Hardpan C1Previo6s Application Made: (If yes,date--------------------) No New Construction: Yes m No ❑ FH'A/VA: Yes El, _TYPE OF INSTALLATION AND SPECIFICATIONS: r (No se tic tank or cesspool permitted if public sewer-is within 200 feet.). I , - i { r. - Septic T Distance from nearest well____,5®___.-Distance from foundation,10---3_`_..M,at� No. of compartments--------_�---- ---Size_!5/xj .x_�rLiquid�d th`_�-s-'----� --------..Capacity-/ �- Disposal Meld: Distance from nearest well---- ��_:_._Distance from foundation: --- _=b/istaAce to nearest lot ling.... Number of lines-----------_ _______---Lengthof-eaChr line/ry_ _ -_ ---Width of french------�- Type of filter material._.._flC�_--Depth of filter mateerlal--__L_- _--__-<'_---Total long+h___________________ E=' -........ Seepage Pit: Distance to nearest well----------------------Distance from foundation..............._r_..Dis+ante to nearest lot line---------------- Number of pits______________________Lining material-----------------------Size: Diameter___------______.________-Depth__._.._._.._........_..........._ Cesspool: Distance from nearest well------------- from foundation-------------------- Lining material..................................... ❑ ' Size: Diameter-------------------------------- -----Depth-----------------------------------------------------Liquid Capacity------.-.-................gals. Privy'- Distance from nearest well___----------------------------------------------Distance from nearest building--------------------------.------.------- Distanceto nearest lot line-----------------------------------------=------------------ ---------------=-------•-•------•------------.----•------------ Remodeling and/or repairing (describe):--------------------------- - - -------------------------------------- .............................................................. I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, Stat law , and r le and re lations of the San Joaquin Local Health District. 51 reed � ------------------------------ Owner and/or Contractor (Signed) ( ] ...Ti#le (Plot plan, showing size of lot, location-of system_in_rela+ion two wells, buildings, eft„ can-_be-plpced on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY--------- �� ------- ------------------------------------------ DATE... ,5- t.- ------`--------------- REVIEWEDBY----------------------------------------------------------------------------------------------------------------=----------- DATE------------------------------------------------------------ BUILDINGPERMIT ISSUED-----------------------------------------------------------------•----••-- ------------------------- DATE------------------------------------------------------------- Alterationsand/or recommendations-------------------------------------------------•--•"------------------------------------------------------------------------------------ ------------- ....................................................-�J� --"------ --_--- -•--�i4o) ------ --------------------- .--------------------------"".-----••-"---•-------•---- ------------------- ______________k_..____.____....__._...__.....__. _____ ________.._._.__._._.__ _ ... ._____ ._ "__-__-____.__ _...__._____.__.__..._.. ___.._________._._____..______. ._._____..___.._____._______ ________ _-_ FINAL ;INSPECTION„,QY . Date == `, _�-_ � { i SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 124 Sycamore Street 205 West 91h Street Stockton,California Lodi,California Manteca,California Tracy,California ER 9 REVISED 5-89 2M 5-61 ATLAS