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�3 j r [`� APPLICATION FOR SANITATION PERMIT Permit No. ___ ___________________ (Complete in Duplicate) a l / Y Date Issued Application is hereby made to the an Joaquin Local Healfh District for a permit to construct and install the rk herein described. This application is made in complianc ''with County Ordinance.No. 9.i y. - TION.- _---___-_-- cJ --- LO ---- --- ------JOB ADDRESS AN Owner's Name------- ---- -------- - -- - - ---------- _ Phone.-/7/10--- Owner's Address ---�------------------ `.. -......::..__�...__ , ... ---- Phone.,//v--- --- hone � �/-�� Contractors Name----- -----'------- Installation will serve: Residence Apartment House ❑ Commercial ❑ Traileri Court ❑ Motel ❑ Other ❑ r Number of living units: __'.___`Number of bedrooms _��Number of baths __�:__�Lot size ___ �_____�.--t.--�-�.--- . ; { r fi 1 Water Supply: 'Public system Comrriuriity-system ❑ "Private ❑Depth tc`Wa'ter' Table Character of soil to a depth of'3 feef —SandQ.,.Gravel-❑Sandy Loam❑ .Clay Loam ❑ Clay [) Adobe ard#oan f• t -_.. .r.w..Mrw ..ww..ww�_.....�...�.... � - Previous Application Made:• Yes 0 No New Construction: Yes ❑ No ❑ +FHA/VA: Yes ❑ ' No { TYPE'.OF INSTALLATION AND SPECIFICATIONS: o septic tank or'cesspool.permiffed if public sewer is available within 200 feet.) . No, of.compartments Size. R------ ----- ---------s Liquid`depth__ tic Distance from'ne est well__________. _Distance from foundation�y� Material____,.__"___:______.___________________________ p - Capacity I71 al a Distance from'nearest.:well•,__:�°`___:r-`_':Distance from foundation--------------------Distance to nearest lot line.---------------- _ Number of.lines = �Lengthof each`line----------•-' ------------Width of french_-------- •----------- -Type of filter material--------------------- --Depfh of.filter.material-----:'--- ----------._Total length---------------------------------0- foundation' �" Distance to nearest lot {ine___�- Seepage Pit:? i.Distance to nearest well____ �_______________Distance ----•- [ Number of pifs______�_________ri--;Li ring material Size: Diameter_ Z...-___..Depth__..,2_ 5________________ Cesspool: Distance fi=om nearest';-well.................Oisfance from foundation____________.:_---.Lining materiaL.-,------------------------------------ apacity Size: Diameter-- Depth---------------- --------------=------ ------------Liquid CapacitY ---------------gals. e l� Disfance froM' nearest building Privy: Distance from nearest well --------'-:.---- --•----------- - --- g -m' `Distance to nearest lot•line -------- ------ -- - ---:--- �-�"-=--------------------- �. - ------_--•-------- Remodeling and/or repairing (describe):- ---� -------- - ---- ---- ---------- --==---- ----- --------- :: ------- - •-- - ....-- ---- ,i . ...,:. It - - - - - --• - --------- I --------------------- ------ ------------------ --------•-------- ---- ------ --------•---------•-----•----------------------------------------- - ---------. --=-----------,------------- 1-hereb cer iffy tha I have pre red this p licatio and j t at the work will be done`in accordance with San Joaquin County ordinances, to laws, d rules anegulati ns f the an .) qui Local Health N District. „ i ,.. ----------- By: - - Contractor) (Signed)..... =------------- -t .•----------------•-•----------------- -�i-�------------------- - i BY�------------------ ---- -------- ----=- ---- ----�-(Title) ---- - - - -------�- ---- - (Plot ,plan, showing size of lot, location of system,in relation t ells, buildings, et ., can be ced on reverse side). T FOR DEPA TMENT USE ONLY. ` APPLICATIONACCEPTED BY- ---=----------=--------=--r-------------------------------- "--------------------------- DATE----.-I--------------------=------------------------------- REViEWED BY - `.� t DATE--:-� ----------------------------------------------- BUILDINGPERMIT ISSUED--=------� ,----------'---- --=--'--------•---------- -- ----------------------- DATE ------------------------------ ------------ Alrerati ns an9r r commendations: . --------- =• ' ------------------------------------------------------------------------------------------- -------------------- - --------- -- ---------------------------- = _________________,._______-_____.---__--___-__- .J___--__-______----- _ _..__..___-___..___- ______.__.__-______--.-- -.=..__________-______... ______---____._______ - . - FINAL INSPECTION` BY:-- ---...C �.�l;��_.r----=-�.'�-k- ------------- Date----"-- =---�-= i ---------------------------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Street 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California ES-9-2M Revised 1.57 F.P,CO.