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F R FFICE USE: 3O � • APPLICATION FOR SANITATION PERMIT Perm i+ Na. (Complete in Duplicate) Date Issued ------_---____------------------------------------ This Permit Expires 1 Year From Date Issued Application is hereby made to the San Joaquin Local Healfh District fora ermit.to construct and install the work here-:n described. This application is made in compliance with County Ordinance IN 549. 4 JOB ADDRESS AN LOCATION.------------ I - - ------- ;� / "'�"D"--�--------•---------------- Owner's Name-- GSC-_-- --- -- - -------------------------- -------- Phone... ------------------------------------- ---- --------••- Address -- --•----- -- - - - ----- ��' -------•------- -------•-------•- Contractor's Name , ' r ----- t Phone... `- Installation will serve: Residence [ Apartment H use ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: __/_- Number of bedrooms '__ Number of baths/____ Lot size o- C>4--- Water Supply: Public system Community system ❑ Private ❑ Depth to Water Table Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobeardpan ❑ Previous Application Made: (If yes,date------_-------------) No ❑ New Construction: Yes ❑ No FHA/VA: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: No septic tank or cesspool permitted if public sewer is available within 200 feet.] SeT Distance from nearest well_________________Distance from foundation____.---.-.--_-.__.Material-____________-_______-__-_-_____________._____- Z No. of compartments-------------------------- l!Size------------------------------Liquid/depth--------------------------Capacity------------//--------- D" osa Distance from neatest well__A_3rtQ.�.Distance from foundation----R-_�_�____.Distance to nearest lot line_j__t�_�___ Number of lines___!_ _ ___ _____________ ____Length of each line---�. _p_-�___- ___.__.Width of trench----� ....__ .............. Type of filter material_+ p --� g -- VI _ __ ___ :____Depth of filter matEr�al________1 ._.___Total len th___�7______________________________ Seepage Pit: Distance to near e t well__�a+______ _______Distance rom foundation__1_&_._____.Distance to nearest lot line___________._ V Number of pits--7------ - ------Lining material__________ ___-____Size: Diameter_-!1______Depth-__, r m Cesspool: Distance from nearest well-----------------Distance fr foundation...__-_______-----_Lining material________-_-_--------_______.__.-_-___ , ❑ Size: Diameter--------------------------------------Depth-------------- -------------------------------------Liquid Capacity----------------------------gals. A Privy: Distance from nearest well __-________________________________----------Distance from nearest building-___---------_x _----_--_---_-_---_..._. [❑ Distance to nearest lot line---------------------------------------------------------------------------------------------------------------------------------------------- Remodeling and/or repairing (describe)- - -•----------• a a -------------------------------------------------------------------- ----- -------- ------------- ------------------------------------------ --------------------------------------------------------- ------------------------------- - ------ ---- ----� � ---------r--------------------------------------- I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, Sate laws nd rules and regulat'ons of th San Joaquin ocai Health 'strict. t [Signed] ------------ -. Contractor] By:-------------------- -----_ •-------------- ------------- --- ---- -------- --- - ---------(Title)----------- :--------- ---------------------- --------- (Plot plan, showing size of lot, location of system in relation wells, buildings,Ac., can be placed an reverse side]. FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY------- ------- - ---------------- -- ` :-G�- -- -- ------------------------------------- DATE-------------- -----�- - ----- --- --•-- REVIEWED BY-------------------------- ------------------ DATE----------------------------------------------------------- ----- PERMITISSUED------- --------------------------------------------------------------------------------------------- DATE------------------------------------------------------------- Alterations and/or r commend tions: -a------------------ ` ---------------------Z - -----------------------------------------------------•---------------------------------------------=-------------------------------------•-----------•--•--------.-.---------------- ------------------------------------- �s - -------------- ----- ---- --------------------------------------------------------------------•------------------------------------------------------------------------------------------------------------ FINAL INSPECTION BY: Al -----rANJCAQUIN s --�------ Date------ l ` v/ 6 LOCAL HEALTH DISTRICT 1601 E.Ha:ellon Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California Lodir California Manteca,California Tracy,California ES 9 REVISED 8-59 3M 3-'S3 F.P.CD.