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FOR FFIC� USE: A` I / ll � ---1111-- -- ��- - -----------1111-- �. - --------- -------------_---_-1111-, APPLICATION FOR SANITATION PERMIT Permit No. ----------- - ----------------------------- --------------1111-- - - (Complete in Duplicate)- �'� - . Date Issued _____..>'3__�.� _________ ________ ________-_.___.___._____.--__-._'. This Permit Expires 1 Year_Fr_o_m_ Date Issued . 'A t, lication is hereb made to the San Joaquin Local Healfh District for permit to construct and install they work herein described. pP* � Y 9 This applicati`n is made in compliance with-County Ordinance No. 549. JOB ADDRESV AND L ATION-------- l - - yam'-"'- -- ---- --- ------------ ----- ---------•---- _--------------------••-------- �� - f Owner s Name_--- --------- -•- - -- -- -1111-- -- 1111- 1111-. _.---- -- �-. - � ne.111••1 ---•• - -- ---- Address------ - -------- - -- ------------ -------------••-• -------------- -----------------•-••---------- -------- ------------------------------ Contractor s Name__________ ___ ! - - -- --•-•-----------------------------------------------1111-- - --------------------- ----------------=1111 Pho Installation will serve: Residence �Apartment House Commercial Trailer Court ❑ Motel-® Other ❑ Number of living units: _1--- Number of bedrooms __ _ Number of baths __ size ._. - � �l_._ Lot -�� 1 .111-�-2--------------------1111-- � Water Supply: Public system Carimunity system ❑ Private ❑ Depth to Water Table ft. Character of soil to a depth of 3 feet-. eet: Sand ❑ Gravel E] Sandy Loam E] 1:1Clay Loa ❑ Clay Adobe Hardpan 0 Previous Application Made: (If yes,date-------- -----------I No g New Construction: Yes)m No 0 PH /VA. Yes ❑ No-q' TYPE OF INSTALLATION AND SPECIFICATIONS: / •(No septic tank or cesspool permitted-if-public`sewer-is-available-within 200-feet) eptici T nk: Distance from nearest well_________________Distance from foundation--------------------Material------.-_--____-______-________-______________- No. of comartments--------••----------------Size-----•-----=----1111---- - - - ` P Liquid depth-----------------1------Capacity-----------•----------- Disposal F' Id: Distance from nearest well-----------------Distance from foundation.-------------------Distance to nearest lot Number of lines__________________________________Length of each line..._--------------------------Width oftrench._.�-___"""�:________________ Type of filter material-•1111-------------------Depth of filter material----------- -_----Total'Isiigth ..-----•------------------------- Se -----------------__..._____ Seep a Pit: Distance to nearest well_, t,� '______Distance fro /r dation __f^ ..-..Distance to nearest�lot`linp.. --------- Number of its_.___. Linin material__ _.Size: Diameter_--`-.h__-.-1__DeptG/- __.- - P /----------- g _ Cesspool: Distance from nearest well------------- --Distance from foundation--------------.-----Lining ❑ materia!__---_______---.----_________________ Size: Diameter-------------------------- ----De Depth ----------------------------------------------•-Liquid Capacity---------------------------gals. . , Privy: Distance from nearest well--------------------------.----------------------Distance from nearest building -'-"`-'___"'____-___--_-----. ❑ .. . Distance to nearest lot line -------------- -•----------------------------------------- ---------------------- --------- Remodeling and/or repairing (describe):___ -- --_ ___ ______- --- -------------•--__.--------;---------------- ----------------------------------------- ------ --------------••--- --- ------ -------- ....-.--------•-----------------••----------••-------•- --•------- -------------- --------- -------------------------------------------•-- --------------------------------------------------------------- ------------•------------------•--•---------------- ------------- -------•------ ------------------------_ ----------------------------------------------------- -----------•-------------------------------••-•----------------------•-•------------------------(---------------------------------------------- 1 hereby certify that I have prepared +his application and that the work will be done in accordance with San Joaquin County ordinances, State law and rules and regulations of the San Joaquin Local Health District. [Signed)--- --- =-- ------------------------------------------------------ (O nd/or Contractor) B ---- ----------------- Y�-------------1111--f-��1111-- -----=-�f� --- --------------------------------------------1111-- •��[rtl,'1111-- -1111-= - (Plot plan, showing size of lot, locafion of system in relation to wells, buildings, etc., can'be p aced on ver side). ' FOR DEPARTMENT USE ONLY , .- APPLICATION ACCEPTED.BY1111-- •- ------ ----------=1111 1111- --- DATE--------------1111-- - -- �>�------------------- REVIEWEDBY----------------------------------- --------------1111._ --------I------- 8---------•------------------------ DATE------------- ----------•----------------------------------- BUILDING PERMIT ISSUED- " `=_=�------------------------ DATE----- AlterationsandAr r recommendations:_---------------------------- -----------------•-•-------------------•-•----_------------._..._....�..--------------------•--•1111-- -....1111-•-•---•-1111-- -_(------- �. .-0; _ - ------------------------------------------------------------------------------------------- - -----------1111------------- ----- 0--- ----------------------------1111-- - ----------------- -••------------------- ------------------------------------- ---- ------------------------------------- " - -----------`--------1111-- ---------------1111-- -- ----------------------------------- -------- ------------------- ---- -------- ------------------------------------------------------------ ----------------------- ------ FINAL INSPECTION BY:- � ------------------ ------------------------------- Date-------J-------`a�- ' 1 111--•---- -• -- ---------------------------1111-- " SAN JOAQUIN LOCAL HEALTH DISTRICT +` 130,,�South American Street 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,,,Californla Lodi,California- Manteca,California Tracy,California E8.9 REVISED 6.59 F.F.CO.2M 6.60