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J FOR OFFICE USE: 4 - ' - APPLICATION FOR SANITATION PERMIT Permit No. ___ ... .Z.. /- I( t (Complete in Duplicate) `� �. IM ------ This Permit Expires 1 Year From Date Issued Date Issued ..... .....7.._ .:. Application is hereby made to the San Joaquin Local Health,District for a permit to construct and install the work here descrbgd. This a.ppI'cation,is made_in__campEiance with County Ordinance No. 549. q &)3 f =JOB ADDRESS-AN[ A --- ---------- - --- ----- p iN.. ` M f---y------- c ------.Phone-------------------------------- Owner's Name Address_____. . -----...--•-- 3 �e Contractor's Name------------ ---- ------------------------ •••---•--- Phone---"--------------"-•----•-------- tnst�a Ilation will serve: Residence MApartment�House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units!" ./--- Number.of bedrooms ._ Number of baths ./___ Lot size __ _ . ....... ---------------------- I ni Aft. Water Supply: Public system ❑ Commu qty system ❑ Private [ epth to Water 1" ble Character of soil to a depth of 3 feet: Sarid ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe 2_1qardpan ❑ Previous Application Made: (If yes,date ".lI No New Construction: Yes ❑ No 9�?'FHA/VA: Yes ❑ No J2-- TY E 2 — TYPE OF INSTALLATION AND SPECIFICATIONS- sewer (No septic tank or casspfopermitted if public tavailable within 200 feet.) Septic Tank: Distance from nearest well-_ _____Distanclr-�from foundation---,�e........Mate2 L_(®_&._9 ----------- Xe Dispo field: Dotance partments" _./2-----------------Size_ .+x__ ------ Liquid depth_.._ __ Capacity...Zn-e........ from Weare WOW- Distance from foundati n....l _......Distance to nearest log line.J........... (A Number of lines__________ ________ ______ Length of each line----x�Y___ -_-...... of trench__g.._ Type of filter material., __Depth of filter material...-. _.___..._._-Total length_-_-...�':_-V...................... Seepage Pit: Distance to nearest weIlA_1t9�_ . Distance from foundation_...AQ-....___.Distagre to nearest lot line. Number of pits----0,----- _____Lining material--- �_a .Size: . '�..... Diameter__3J-_.______-.Depth_p_s�'�__._.______._.___. Cesspool: Distance=,from nearest well----------------- from foundation--------------------Lining material____._._____________________________ Sze:�❑ Diameter-----------------I------- ------- -."Depth--------- -----------------------------------Liquid Capacity__ gals, Privy: Distance from nearest well_____________________________________________�Dista.nce from,,nearest building______._____________________________--.... �❑ _ Distance to nearest lot line--- ------------ ----------------- ----------------. ------------------------------------------------------------------- ------------- f 1 (A Remodeling and/orrepairing (describe):--------- •4 --- - ---- --- ------------------------------- IM ! t -------------I----------------------------------------------------------------------------I................................-----------------------I--------------------------------------------€ -------------------------------------- ----------------------------- 4_zi! ----------------------------------------- ----------------------- ------------------ - - --------------------:- -------•-------------------------------------------------- i 1 hereby certify that I have prepared this application and that the work will be done`in accordance with San`Joaquin County ordinances, Statellaws, and rules and regulations of the San Joaquin Local Health District. ' �� 4� (Signed] .. y ----- ------- ---------------- ---------------------- Contractor) Plo# Ian, showing size of lot I� �.v • ��" 1 _ �. By:--�f{• --------------------------------------------------------------- ------------ (PW --__---Title) ( p g , location of system in tion to wells, buildings, etc., can be placed on reverse side]. f� )FOR DEPARTMENT USE ONLY 1 s APPLICATION ACCEPTED BY DATE-"-----"---- ------ REVIEWED BY ------------•-- DATE------------------------------------------------------------ - BUILDING PERMIT IyS�1SUED^---�---}---------------------r_"___ _-_-_-----�---------------G4 _Ss_' _r_�-------------- DATE---------------------------------------------------- -�Alterations and or recommendations:--- 7_ - . ---•- ----------------------------------------„-- --- $ I IM ";; f I li E- t- 7yf�i9m�rtis A FINAL INSPECTION BY. "1_ ,-- �..�.----------- - - r----- �'�--�----- Date---:`--�--- - ---------------- �, SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American StvRet 300 West Oak Street 124 Sycamore Sfreet__ — '"'"' Y"-"205 West 9th Street Stockton,California Lodi,California Manteca,California Tracy,California a ES 9 REVISED 8.59 2M 5-62 Att.AS