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A <br />FOR OFFI�E UE: <br />Permit <br />143 /_3 No. --------- <br />--- ----- APPLICATION FOR SANITATION PERMIT <br />-------------------------------- <br />----- (Complete in 40 <br />Duplicate] Date issued ............ <br />--------- ------------ -- ------ ----------- ----------- From Date Issued <br />1 This Permit Expires 1 Year Fir <br />------ ---- --- - - -- ----- -- ----- --- . <br />Appi - i - cai: - ion ... is .- hereby - - __ made - to . the San Joaquin Local Health District for a permit to construct and install the work herein described. <br />This applicatii is -made.in,com )Iiance with County ordinance No. 549- <br />JOB ADDRESS AND LOCATIION--IYOr__eo�C-1-�7,�,?Aa Phone ------- -------------------- ------- <br />Owner's Name ---• I-I-1 - VK�o Irl-140916101, - .6 ------------------------------------------------ ---------------------------- <br />1!2 �- ------------------------------------------------------------- ­1 ....... --------------------------------- <br />------------- ----------------- <br />Address ------ 1w - - - A_ le - .0, <br />Contractor's Name -------- I ---------- xt . , --------------------------------- Phone ----------------------------------- <br />Ice - -------- ----------------- ­ ----------------------- <br />Motel 0 Other 0 <br />•idence 0 ApaftnrI �`Ious6'-D Commercial t3 Trailer Court [] , 11 r <br />Installation will serve: Res Z Lot size .01I X-1?1,51 -------------------------- <br />Number of living units: ---/- Number of bedrooms _,�­Number of baths/I AVI ; <br />—Water Table ;?w ft <br />Water Supply- Public system El Commurilty",systern [] Private [] Depth to <br />Character of soil to a depth of 3 feet: 'Sand [] Gravel 0_ Sandy Loam E] Clay Loam Clay <br />C] Adobe 0 Hardpan ❑0 <br />Na New Construction Yes ZKRo FHA/VA. ❑ <br />yes <br />Previous Application Made: (if yes,dote ---------------- <br />TYPE OF INSTALLATION AND SPECIFICATIONS: <br />(No septic tank or cesspool permitted if public Ir, sewer is available within 200 feet.) - - - -------------- <br />Septic T nk- Distance from nearest well--40 -------- Distance qm foundation ----- /R ------- M <br />akial ---- C -, <br />4 .1 !�X_w!."v -...........�Capacity_- -- - -------- <br />--Liquid de.p1h ---t, <br />No. of compartments ..... �? ------------------ Size r: . if <br />.1 ation --- / I ---------- <br />Distance from nearest well__ <br />Distance from found r --------- Distance to nearest lot line. e' <br />Disposal 'ield: - Width of trench---,Z -- ---------- ------------- <br />------- Length of each line..z ------ <br />er <br />Type of filter m D ---- ------ Total length--- <br />Number of lim Z th of filter mat ial -- --------- <br />aterial-4P -I lep <br />f m foundation--A .... Distance to nearest lot line_................ <br />rest well-­/ <br />Distance pg <br />Seepage it: Distance to nearest --.Size: Diameter----, pth ..... <br />.F!?� ------- De <br />Number of pits%; ... / -------------- Lining, material-_/I <br />Distance from - nearest well e from foundation-- . ............... "".._"-.Lining material-------------------------------- ----- <br />Cesspool: -------- ------- Distanc Liquid Capacity ---------------------------- gals. <br />------------ Depth ----------------------------------------------------- <br />Size: Diameter------------------------- . Distance from nearest building-._" .................•------------------ <br />Privy- Distance from nearest well------------------------------"" --------------- � ­ ----------------------- --------------------------------------- _ �h <br />Distance to nearest tot line"._ ......... ------------------- -------------------------------------- It <br />-------------- ------------------------------------- <br />Remodeling and/or repairing (describe): ------------- --------------- I ------------------------- <br />1 ------------- ------------------------------------ -------------------------------------------- ­ I <br />----------------------------------------------- ------------------- <br />-- --- ----- ------------------- I ------------------------------------------- --- ----------------------------------------- <br />------------ I -------- <br />------- -------- <br />--------------------------------------------------- <br />------- --------------------------------------------------- <br />-------------- <br />--------------- I -------- --------------------------- ------- <br />--------------------------- <br />------ --- -- - - -------- <br />--------- I -_ hereby - - -_ certify- -_ that .- I -_ have prepared this application and that the work will be done in accordance . with San Joaquin. County <br />ordinances, State laws, and rules and regulations of t 6 San Joaquin Local Health District. <br />- Ior Contractor, <br />---- ----- ---- ------------ I ------------------------------- (dgisg� <br />- - -- - ---------- ------ <br />(Signed) -------------------- -- --- - ---- ---- ------------ (Title) ----- ------ <br />Y <br />----- ..................... <br />B: ------------------------- --------------------------------------------- -- <br />(Plot plan, showing size of lot, location of system elation to wells, buildings, etc., can be placed on reverse side). <br />FOR DEPARTMENT USE ONLY <br />DATE---- <br />ATE --- _q ------ -------------- I ----------------------------- <br />7 Y ----------- -------------- - - ---------------------- <br />APPLICATION ACCEPTED BY ? <br />----------- DATE ------------------------------------------------------------- <br />REVIEWED BY -------- ------------------------ <br />---------------- I - ------------- I ------------------ DATE ------------------------------------------------------------- <br />BUILDING,PERMIT ISSUED --------------------------------------------------------------- — -------------------- ------------------------------------------------------------------------------ ------- <br />Alterations and/or recommendations:-": ----------------- : ------------------------------ ------- -------- --------­-------------- <br />------------------------- ---------------------------------------------------_- <br />- ----------------- ------------ I -------- I -------------------------- ---------­----------- 1. ....... I ........ I -------- <br />--------- --- <br />-------------- ---------------------------- <br />---------------------------------------------------- <br />------------------- ---------------------------------- ---------- --------- <br />------------- - ----------- <br />- ------------------------------------------- --------------------------------------- - <br />---- ----------------------------- ­­ - --------------- -------------------------------------- - ----------------------------- --------------------------------- <br />�7 <br />Date---------------------- ----------------- <br />FINAL INSPECTION BY'. . ..... - ------------------ <br />SAN JOAQUIN LOCAL HEALTH DISTRICT <br />124 Sycamore Street 205 West 9th Street <br />300 West Oak Street I V - <br />130 South Am erl can Street k % I I.M6 nteca, California Tracy, CaliforniaStockton, California Lodi, California <br />REVISED-0-59 F.P.Ca, 2M 6-60 <br />