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FOR OFFIC USE: ? � ------------------- ------------------ ii APPLICATION FOR SANITATION PERMIT Permit No. ...1 .. ------------------- ------------------------------------- ` (Complete in Duplicate) Date Issued --------------------------------------_-.------------------ This Permit Expires 1 Year From Date Issued ..-•-,_-_-.� �l , 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. f- JOB ADDRESS•ATION----_1� 12 ---9��e ------ - --------------------------------------•-•--------- Owner's Name---- ---------------_ - _- ------•---- ------ -- - --------------------'-------------------- Phone........................----------- --------- ----•----- ------------------- ----- - ------- .- C= ---- Address ------------- --- �.Z � ply r: Contractor's Name_ . l{._ 1`-- -. i�.#_:___ -C.S.`C.. Phone.. Installation will serve: Re ' ence (C-] Apartment House`❑ mmercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: ---,�Number of bedrooms ____ ___ Number of baths �t size ______�aT__--- Water Supply: Public system '1 arnmunity system ❑ Private ❑ Depth to Water Table _6Dft- Character of soil to a dep+h of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe -lardpan ❑ ' Previous Application Made: (If yes,date----------- ------} No ❑ New Construction: Yes E] No ❑ FNA/VA: Yes E] Na El u TYPE OF INSTALLATION AND SPECIFICATIONS: o septic tank or cesspool'permitted if public sewer is available within 200 feet.) ii tic T Distance from nearest well_________________Distance from foundation------------.------.Material--------------------- ____________..__..__._.-. No. of compartments s- well- Size--------------------------------Liquid depth--------------------------Capacity__________-_.. p rtments__ -- --- r i osal '+cid• Distance U Distance from foundation._�.�..____.Distance to nearest lot line_-_ �V Number of lines_____-_- _ . ______._ Length of each line---_1s5___-_--r____.Width of trench------------ _-________ Type material �l�__-.__Depth of filter maferial!eC?# _____Total length______________l ._-.. y T e of filter Y N epage it. Distance to nearest well____ Distance rom foundation_I. _�_:_.-.. istance to nearest lot line---_ IV Number of pits--I-----------------Lining material.-P_--- - -_- ---Size: Diameter_-- _-� �1-------Depth-.__- �.._.--_-•-- Cesspool: Distance from nearest well_________________Distance from undatmn--------------------Lining material--------.---------------------------- ❑ Size: Diameter------------------ --------------------Depth--------------------------------------------------Liquid Capacity------ -----•- gals. Privy: Distance frod nearest well---- `__ ____ _____________F_ .._Distance from nearest building_-----_._______y_______-____--.____-_.._. ❑ r *---------------------------------. ---- . ---------------------- ------------------ ------ ., wDistance to nearest lot line----- ------- ---------------------- Remodeling and/orirepairing describe}. F .::--------- ------f -s' ------=- ----•------------------•----- --- -='—--------- _ ° ' __. `'- �' - --•--•------------- --•--------------•-- ----------------------------------- __-__-___.__ter____ --_____�_________________________.-____ I hereby certify that I have ikA prepa ed this application and that the-work will be done in accordance with San Joaquin Coun+y ordinances, State laws, an rul�nd regulations of the San Joaquin Local Health .District. �--� cC �,,� (Signed)- -2-r , ``-`------- -•--------------------------- -- -- --------------------------- -- Contractor) �•. By:______________________________ _______ -------------------------------------- _____________ 4 _ ________________________________________________ _ ___ _ __ __ _______________.----____..________...__.. (Plot plan, showing size of lot, location of system in relation to wells, ildingsr etc., an be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY ------------------------------ DATE------'2 J-- -- ------------------•---- ------------- BUILDING PERMIT ISSUED--------- DATE - REVIEWED BY--------- _ ----------------------------------------------------------------=------------- --- ---- DATE--------------------------------------••------------------- Alterationsand/or recommendations:------ ----------------------- ------ --------- -----------------------------------•---..---------------------------------------- ----------------------------- ---------------------------- --------•-•----,----- -------------------------------------------------------------------- � - _ ----------------- ---------------•-- --------------------------------------- --------------------------------•------------------------------------ --------------------------------------- -------- --------------------------------- ---------1-------------------------------------------------------------------- ------•---------------------------------- --------------------------------------------------- FINAL INSPECTION BY:-cam< �t �� Date-------- �"�-'---7 / - w,dSAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street300�west Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California �'v ��``' >{"cLodijC61ifornua Manteca,California Tracyr California ES-9 REY19ED 9-59 F,P.00.2M 6.60 -