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FOR OFFI(;E USE: Z, 1k tl - f, - .- - ------------------- APPLICATION FOR SANITATION PERMIT Permit No;, ..�.�j.7. V, ----------------------------- ------------ (Complete in Duplicate) ? 7s This Permit Expires 1 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. 49.e l JOB ADDRESS AND CATION_.__-.--- _- --------- lop e 16t -- -------------------------_ Owner's Name -------- ---- ------•--- Phon ��-�-1 ••-• F 1 i iE Address == ------- ---•-•• --9-- ------------------------------------------------- Contractor's Name.....`........-- --•-- ..... •-•--•---•--••-• ..................•-------------------------- ............... Phone/-f{ _.-_ _ ....Q Installation will serve: Residence �partment House ❑ Commercial ❑ Trailer Court ❑ Motel [I Other El Number of living units: .__ Number of bedrooms _®z- Number of baths _/_ Lot size . Q_�1�� 0 I Water Supply: Public system - Community system ❑ Private ❑ Depth to Water Table,. ft Character of soil to a depth of 3 feet: Sad ❑ Gravel ❑ Sand Loam ❑ Clay Loam ❑ Clay ❑Adobe P-_ ardpan ❑ Previous Application Made: (If yes,dote.--#--- -- ------ -------- No New Construction: Yes ❑ No [}[}�HA/VA: Yes ❑ No ❑ I TYPE OF INSTALLATION AND SPECIFICATIONS: It. eptic tank or cesspool permitted if public sewer is available within 200 feet.) Distance from nearest well............:....Distance from foundation--------------------Material......... .-..................................... . No. of compartments--- ---------- -r_ t�:Size--------------------------------Liquid depth................----------Capacity........=---..._.._�_ Disposal 'e Distance from nearest well - - - .------Distance from found ion..f o------.--_-Distance to nearest ot Iir9e_,le--__.-- Number of lines.__...__.. Length of each line, Q_-- -- ff_-_--.Width of trench--7-' ( -------r------- I Type of filter.material._- - 6Depth of filter material--f ----------Total length--------------- ....... i s� Seepag E : Distance to neares e .:-_. r n ,� Distance foy n'dation--._ __f�_--....Distance to nearest lot line Number of pits---.-/------------Lining material ---- .(_CI .Size: Diameter-_-,93___"0 ---•Depth......Z5-•................ Cesspool: Distance from nearest well.................Distance from foundation--------------------Lining material...........----------_----_---_.-.___ ❑ Size: Diameter--------------------------------------Depth----------------------------------------------------Liquid Capacity----------------------------gals. - Privy: Distance from nearest well----------------------------------------- ----- ._Distance from nearest building------------------------------------------- # ❑ Distance to nearest lot line---------------------------------------------------------------------------------------------------------------------- }~ 1 Remodeling and/or repairing (describe)--------------------------------- - -----------------------------------•........... -------------- 1 i 1 ---------------------------- ---------- ----------------•-------------------------------------------------•---------------------------------------------------------------------------------------------------------------- jI hereb rtify t 1 have prepared this application and that the work will be done in accordance with San Joaquin County ordinances s, and`rules' d regulatio of the San Joaquin Local Health District, i (Signed)......... • • --- ---•--•• y F; ----••-------------------------- ------ --- ----- nd/or Contractor) //� �� It Title - ----- —. .� — By:-------•-------- '---••--•---- - ( } ...... (Plot plan, showing size of lot, to ation of system in rola ' n to wells, buildings, etc., can be placed on reverse side). *� FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY- - Y - DATE - d5t1 !� REVIEWED BY----------------- -------------------------------------------------------- DATE------- :_ DATE BUILDING PERMIT ISSUED-__---------•------------------ ...------------------------------------------------- __ _ Alterations and/or . .............. --------- -�- ---,!- r'I' _------_--- ___ .:FIS-` --_---`�`-,Jv-.!+,y •___I _----1�' .C ---------------------------vt.-.-.-!. -... _fes-.- ..-_-•--- - !--ed�%.---�!r:--. _. _�� - --- - !'4''--.-.---------------- ----_------_--• ----------- -- i�-,/ / -._-�•-- .-..---- � � s� ± �� r FINALINSPECTION BY:---------------------------------------------------------------- Date.................................................------------------ ----------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Surest 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,California Manteca,California Tracy,California ES 9 REVISED B-59 2M 6-61 ATLAS �.r