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AOR OFFICE USE. t APPLICATION FOR SANITATION PERMIT Permit No.--------------------------------------------------------- ...!__ -_... ..,.. (Complete in Duplicate) I (� DateIssued �'___ This Permit Expires 1 Year From Date Issued $ __.�..--E.---.------ 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. JOB ADDRESS AND LOCATION ------ �. 1' -- { f 0�- � 1h �L`- Owner's Name =.1.��. k '-----.KN E-•----.-•------------------------ V-- ------ Phone --`3_. Address .—.. --Y _7 - .. --- ........................... . ..............-------------.------------------..W. .............. Name-------Ql�'��}.��.�------------------------------------------------------------------------.---------------.....--------•---- Phone........I 1_...-_-----------. ---- Installation will serve: Residence ��Apartment House [I Commercial [3Treiler Couat ❑ Motel ❑� OtL ❑ Number of living units: 1.... Number of bedrooms ~�_... Number of baths _ ..__ Lot s e _//.JJ --- -.=- Water Supply: Public system [] Community system ❑ PrivateDepth to ater Table ':?3_-_ ft. { Character of soil to a depth of 3 feet: Sand ❑ Gravel L3 Sandy Loam Clay Loam ❑ Clay❑ Adobe❑ Hardpan ❑ Previous Application Made: (If yes,date____________________) No New Construction: Yes No ❑ FHA/VA: Yes ❑ No [T�� TYPE OF 114STALLATION AND SPECIFICATIONS: (No,septic tank_or eesspool_permitf dJf public.sewer..is available.within 200:feet.]l Septic Tank: Distance from nearest well_________________Distance from foundation--------------------Material..___-_________.______--------------.-.-_....... }��G ._ Jr No. of compartments--------•-----------------Size----- -_------------------.Li uid de th_..._...------- -------Ca aci Disposal Field: Distance from nearest well____ .__.Distance from foundation.__ ..Distance,to nearest lot line__. ! t'vC-� Number of lines______________ Length of each line.....____ -_.Width"of +ranch__ ="_ 2 ; F}]7� . Type of filter material...-- C3 _.Depth of filter material___---Ie—___- __Totak length.... '__ .•. .................. ". I Seepage Pit: Distance oto n}rest well- Linin material a from founds Sti ize:nDiameterl Distance to nearest lot line..•______________ ❑ Nu p. g t;- Depth ' ------------ Cesspool: Distance from nearest well----_-----------_Distance from foundation___._. ------3 Lining'material_:________'________......_.__.___.. ❑ Size: Diameter----------------------------•---------Depth-------------------•------- ,._ -- '-Liquid;Capacity-------- -----------------gals. PrivDistance from nearest well_____________________________`__-_-_________._Distance from nearest building_____I--_______'._....- _ y: ❑ ----------�= � t f -------------- Distanceto nearest lot line-------------------------�---�----------------------------....--------------------------...,..._.:---------------------•--....-- i Remodeling and/or repairing {describe _ST V------ A/#;$-------�� 1 r2......... r.... 3_.....- 3AJAB0KD......RAA------1 .N �.►�.� rte_-=_._ �4 1. ,. Ramona.n��nfD�-----�--•---1�1.M----- - 5------��_..---�1�0��n..r!4��----•��'��-..__a��. - �lalSri�R U_ll:WOPOt_ ----14SA------ 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 regulations of the San Joaquin Local Health District.' ' ------------------ ----•------------------------------------------------------------------------------.----------------_:..---(Owner and/or Contractor) (Signed) ............. By: -------------------------------------------------------------��--�(Tiltle) --------------- ---:-� -:: - " (Plot pplain showing size of lot, Iota+tom of sysfem—"i e anon fa wells,'buildings, etc., can be placed on,reverse side}. FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY.---.--.--/___+_ �_ � ` � DATE ti�7. ..__ �`' REVIEWEDBY.............€_----------------------------------------------------------------------------------------•------------------ DATE-------- ------------- -----------------.-------------- i3UILDlNG PERMIT ISSUED ---------------------_ ti DATE ----------------------------- tons an or reComme -/S / Ft 1 = ...... -1�V �.e.__. !#I��_l�..._F PCTH�� L. !�K bR►141iu �tRS_.__.. TI4rR1 �' f. ...---....jC.CAu�4TFD---`---10d C5-. -• �N�-D� vE -----= ---------------•--........ ------ •- -------- ---=---------------- �?i5T, -ek- P. P 1AI TA LL D -'------- �.K - rc1�. ray r FINAL INSPEC N BY:. Date.. - ` �-' SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 121ycamore Sir* 205 West 9th Street Stockton,California Lodi,California a ea,Californlay Tracy,California ES 9 NEYISEP B-59 2M 5-6t ATLAS -