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FOR OFFICE USE: .-_----------- ----------------------------------- --- APPLICATION FOR SANITATION PERMIT Permit No. ..!_i .'_'' rte----------------- ----------------------------- L (Complete in Duplicate) { P P- ) Date Issued --________._.__.__.._................................. This Permit Expires 1 Year From Date Issued Application is hereby made to the San Joaquin Local Health District for a perm' o construct and install the work herein described. This application is made in compliance with County Ordinance . 549. JOB ADDRESS A CATION.... . ... ... ...1--40--t---- --- �--� ---_----------- •--.......------ Owner's Name---- - -------- ---=¢ ' � -----•------------- Phone . . -- Address.-•-•••......-•-••-...........•-- -•-•..........: . •• . ..•. ••........ ------------ ------------------- __.....-----•-•------------- - ! Contractor's Na ------------- -- ------------ -_ -_ C? .�.-. Phon . Installation will serve: Residence_7fipartment House Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ l � Number of living units: .__ Number of bedrooms 7 K_ umber of baths f____ Lot size ---/ f �--------•--- Water Supply: Public systemnmmunity system ❑ Private ❑ Depth to Water Table -------- ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobgd ardpan ❑ Previous Application Made: (If yes,date----.--------------.1 No ❑ New Construction: Yes ❑ No HAMA: Yes ❑ No ❑ F INSTALLATION AND SPECIFICATIONS: {No c ank or cesspool permitted if public sewer is available within 200 feet.) Se nk: Distance from nearest well_________________Distance from foundation------------------.,Material................................................. No. of compartments-------- -----------------Size----------------------•- • ---Liquid depth-_----------------------- s 1 lel Distance from nearsWwell-- ,069 Distance from foundation .__I__..____._.._...Distance to nearest lot line-_-__1........ �L Number of lines___ _ -Length of each line_....-_ta �- _. ____.Width of trench._._ ��.___..__: p //// Z4' �l F_ Type of filter mater --Depth of filter material.._. Total length .�_______________________ Seepage Pit: Distance to nearest ______________ ___Distance from foundation....................Distance to nearest lot line-_-_________.__.. ❑ Number of pits______________________Lining material----------.------------Size: Diameter-----------------------Depth_________._____-•_•_-.__._---_--- r Cesspool• Distance from nearest well-----------------Distance from foundation___________________lining material________-__________----•-_-_--------_ ❑ Size: Diameter----------------------------•---•-----Depth----------------------------------------------------Liquid Capacity----------------------------gals. rr Privy: Distance from nearest well-------------------------------------------------Distance from nearest building___________________._-_- .......::._:.._. ❑ Distance to nearest lot line.----•------------- --------------------------------- •-_------------------------•----••--------------------------------------------=----- Remodeling and/or repairing (des I ----- •--........•-------------•--------------------------------. _:d -------------------------------•----- ----------------------------------------------- ----•-• - ----- * •---•-•. ------------ •. •--•--•--••---- ................... - -- -• ------�- •--- lw� --------------------------- ---------- --- I hereby certify that I ave prepared this application and that thew will be done in accordance with San Joaquin County, , ordinances, StA1aw wn#rules regulations of the San Joaq ' ocal`Health District. {Signed}..__ ------ ---- - -- -- --- ------ --=- --------- ------------- Contractor) --- By:............................-- •----- •-------------------------------------- ' {T'itle} (Plot plan, showing size of lot, location of system in relatio wells, buildings,01c., can be placed on reverse side). FOR.DEPARTMENT USE ONLY APPLICATION ACCEPTED BY. -� -----------------•------------------------------ ----- REVIEWEDBY----------------------------------- ---- -----------------------------•-- --------------------------------------------.... DATE-------------.--------------------------------------------- BUILDINGPERMIT ISSUED.....-•---------- ---------------------------•--------------—-------------------------•------------ DATE------------------------------------------------------------- Alterationsand/or recommendations:--------------------- -------------------------- ----•------------------.----------------••---•--------•----•--•-•----•----•----------_-----•------------------ .-----------•-••----------------------------•-----------• ------------------------------------------------•---------------•---••------------•----- ------. --- I -----------•------••-•------------------------------------------------------------.---------------------------------------------.-------------------------------------------- ------------------•----------------•-- ------•-----------------------------------------------'•-•--•-_.... ----------•------------------------------- -•--------------------------------------••----•--------�------------- ------------------------ ----•----•------.- F]NAL INSPECTION BY:--- _. ____ Date----- --�- ��- --•------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,California Manteca,California Tracy,California ES 9 REVISED 9-59 2M 5-6[ ATLAS