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FOR OFFICr, US : ,> y 7,�5 ).i- _�__ .' ----_ ` ' APPLICATION FOR SANITATION PERMIT 0Permit No. ... . : ------------------------------------------- (Complete in Duplicate) Date Issued ------------------------- This Permit Expires 1 Year From 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 compliances with County Ordinance No. 54/9. JOB ADDRESS AND LOCATION....=/_1c,S�- GL �a1__------------------------------------ Owner's Name C- - + l!� Phone ------- ---- Address.-"-•----"•_•_` -----•-- -•._"----------------•--------•------ Contractor's Name------•---- �..-- - --------"-�-----------••------ ••---------•----•-•-••------••-----------•- - •----------------------------------------------------------------------------------- Phone-------- lnstalla+ion will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ 1 Number of living units: ___I _ Number of bedrooms _--�1_`Number of baths I... Lot size _--12,__��. .............................. Water Supply: Public system ❑ Community system ❑ Private [Depth To Water Table _4 eft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe Hardpan ❑ Previous Application Made: (if yes,date------------ -----) No New Construction- Yes ❑ No ff- 1=HA/VA: Yes ❑ No TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Sept' Tan Distance from nearest well-----------------Distance from foundation--------------------Material-----------.---.----_____-_-______----__--------. No. of compartments -_.-• --------•- p -----"Liquid depth--------------------------Capacity......-............... " Dit o 44!, -f Distance from nearest well-670.....Distance from foundation_�/Z1� ........Distance to nearest lot line)_©, .... � Number of lines............I---------------------Length of each line------ZO...-_.............Width of trench-__-_ -,_-_--------------- .__ Type of filter material__�_/?.UG*_..._Depth of filter material_ r.`'___.._...Total length....___-Z.42................ ________ Seepage Pit: Distance to nearest well--- ------Dista rom foundation-119_ Distance to nearest lot ❑ – Number of pits------/-------------Lining material-__KO_C_.4'......Size: Diameter--!�_--_-------Depth-__c2.eC !--___-------- 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------------------------------------------ F1Distance to nearest lot line------------------------- ---------------------------------•-•-"-"-----------------•----------------------------------------------------- Remodeling and/or repairing (describe):--------------------------------------------------------------------------------------------------------................................................. ---------------------•------------- ------------------------------•---------------------------------------------------------------------------------------------------------------------------------------------------------- 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 regulati of a San Jo quin Local Health District. (Signed)------------------------------------------------------------ -------- ------------ --------------------------- -----------------------------------------(Owner and/or Contractor) By:----------...__.- ------------------------------------------(Title)---------------------------------------- ---- -- ----------- (Plot plan, showing size of lot, location of system in relatio to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY / APPLICATION ACCEPTED BY_.-_... ' ---- DATE.... 1- _ - -- -------- ------ -- --------------------------- - -- --- ----- REVIEWEDBY--•---•-------••----•--- - -- ------ ••-------•--•--•-•----------------------- DATE-_-•----•-------•--•---------------------------------------- BUILDINGPERMIT ISSUED............---------------- ------------"- '------------–----------•----------- ----- DATTE.--------------------- - - Alterations and or recom enct f* ns:__.___ _.�ti - _ I' _r� �_- _ __ _ _ � _____________ 1-111,olt- _. = :--------------------- ---7- --- -� f FINAL INSPECTION BY:------ (� 9 Date-------- -�----• ----------- ---------•---- SAN JOAQUIN LOCAL. HEALTH DISTRICT 130 South American Street 300 West Oak Srreet 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,California Manteca,California Tracy,California ES 9 REVISED a-59 2M 5-62 ATLAS