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rUKUrrlC.t uJt: ------------------------ ---------- APPLICATION FOR SANITATION PERMIT Permit No. _.�. 1%... ------ -- ----•---- - ----- ----------------------------- (Complete in Duplicate) __-------------------------------------------------_--- This Permit Expires ] Year From Date Issued Date Issued _.............. .... 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. S49. Z,ra IV10-1 2- _7il:Fair J ADDRESS AND LOCATION------ Q�_ 80X-- ---------l}l t?y---15------. 'o Y-- .--... Owners Name-----Gtr ocle..---OAS--•-------C6 ----------------------------------------- ------------ Phone.7k.! Address .SRI37 -------•--------•-••---•--•----------_--•----------•- Contractor's Name--- �-J.'Pev------'- -------------------------------------•---•--- Phone,14!691115" Installation will serve: Residence ❑ Apartment House ❑ Commercial Trailer Court ❑ Motel ❑ Other ❑ Number of living units: ____--- Number of bedrooms ________ Number of baths -------- Lot size ___.___�----tem-------------•-__-•-•--__---_ Water Supply: Public system ❑ Community system ❑ Private Depth to Water Table :;�O ft. Character of soil to a depth of 3 feet: Sand Q"Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe❑ Hardpan [IPrevious Application Made: (If yes,date_________________-) No ET--New Construction: Yes El No �HA/VA: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) CIS Septic Tank: Distance from nearest well_________________Distance from foundation--------------------Material---_____-______.___---_---•-------._-._.___._-_-- ❑ No. of compartments--------------------------Size------------------------------.-Liquid depth.................•-•------Capacity....................... Dispos Field: Distance from nearest well--- Distance from foundation......... ......_.Distance to nearest lot line......S.._...... dol Number of lines-----------a--------------------Length of each line_JrL'�7�1EC1�7�=_.Width of trench___.______&d`__`.'____._____..__ C 'Fx1s'i7 Type of filter materiaI._.__tht-_G:&------Depth of filter material______2_*_"--_-Total length-----------Z'7:$................... �? � Seepage Pit: Distance to nearest well----------------------Distance from foundation--------------------Distance to nearest lot line----.___-__-___-- ❑ Number of pits----------------------Lining material---------------------- Size: Diameter-----------------------Depth-----------------•--------------, 2_ Cesspool: Distance from nearest well.................Distance from foundation--------------------Lining material................--------.-........... ❑ -Depth-------------- -- -- -------Liquid Capacity-------------------- --•---gals. i Size: Diameter------------•------------------------ ------- ---------- ------- - ._ _-....,.. __ - . t') � —Privy:-, — Distance from nearest well_____---------- __'------------------------------Distance from nearest building-------------------...................... . ❑ Distance to nearest lot line-----------•-• -•------•------------------------------------------------------------------------•----•-----....................---..------- Remodeling and/or repairing (describe):__._ ._q/-----� �.W..�"7.7.-��......zw-,Iv ----------------------------------_-.--------- �P -------•------------------•------.------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- I .-•---------•------------------------•--•------ •-----------------------••----•---------------------------•-•--................•------•---•-------------•-•----....•--------•-------•--------------------------- 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 regula+ions of the San Joaquin Local Health District. (Signed) ! � @/ !I`S/ -- -30-01111r4QW------ -------------------- -.--.-- f _______________Owner end or Contractor E By:-----------�Ao=____C7' �ofsy:s+;'am 11 l.----------------------------------------------------------•---(Title)----- A - -- --------- (Plot plan, showing size of lot, locat' n in.relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY------------------------------------------------------------------- --• ---------------------- DATE------------------_---��.. REVIEWEDBY------------------------------------------------------------------------------------- - -- -- - -- ----------------------- DATE.. --- BUILDING PERMIT ISSUED..................... ------- ----. -------------------- - ---- •------------------------ DATE.--- -----Z--- ------ -- •--------•-------- Alterationssand/or recommendations:---------------------------------------------- ------••--•------...-----... ----------------------------------------------------------------------------------- ` - .................... ---•-------- �—� ..................y ------------------------------------------- - . ........... -------------------------------------------------------- FINAL INSPECTION BY----------- --- --- ................... Date-------CG r^ ""... SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 144 Sycamore Street 305 West 91h Street Stockton,California Lodi,California Manteca,California Tracy,California ES 9 REVISED 8-59 @M 5-61 ATLAS F