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rUK vim/ c 6z ,'3-4�.. ------ APPLICATION FORM SANITATION PERMIT Permit No. v ---------- _ _.._.. 4 --------------------------------------------------------- (Complete in Duplicate) -------- --- This Permit Expires 1 Year From Date Issued Date Issued ..... dZ_ Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the w herein described. This application is made in compliance with County Ordinance No. 54% JOB ADDRESS AND ATIO -------------------- ---- ....... ......................•_ ._..._. E Owner's Name......... ......... Ph1... ---------- • - - •-- •-------- ------•----------•----------- ----------------------------------- Address----------.......----• rpm /� Contractor's Name_ �' � 1----- 4------------------- Pho -------tP . Installation will serve: Residence partment House ..Commercial E] Trail 7 Court El Motel ❑ Other ❑ Number of living units: _ ____. Number of bedroom Number of baths ---_._fit size _...__.�_{.r_'._4�..�:�...__�.............. Water Supply: Public system ❑ Community system ❑ Privat depth to Water Table-2--Oft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ obe Hardpan ❑ Previous Application Made: {If yes,dote--------------------1 No ❑ New Construction: Yes ❑ No FHA/VA: Yes ❑ No ❑ TYP F INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) ) e 4 Distance from nearest well-----------------Distance from foundation------------........Material.......................................... ......`]/ No. of compartments-------------------- +Size---------------•----------------Liquid depth--------•-----------------Capacity------ �; / osgl Id- Distance from nearest well.19�Q- _Distance from found*fn...�_®_._______Distance to nearest of line ..�-%A • --Number of lines______... ______ __ ________Length of each line_: D__!-_._...__._.Width of trench..._ _.�!...___�_____. A� Type of filler materia�t �-Depth of filter material. _ __Total length--------------- -...Q..........._ Seepage Pit: Distance to Weare t wefl_�_Q_6 _____Distance Tom f undation ��D'st ce to nearest lot line-------------- t Number of pits____________________Lining material�_QG_K---Size: Diameter, Cesspool: Distance p s ce from nearest well-----------------Distance from foundation---.----------.._._.L1n1ng material_.._____._...__..........___._-_-_-__ ❑ Size: Diameter---------- -•--•-Depth-------•------------------------------- --------Liquid Capacity---------------•---------.-gals. Privy: Distance from nearest well-----------------------------------------_-------Distance from nearest buildingCl Distanceto nearest lot line---------------------------- --------------------------------------------.-------------•-------------•---••--------------•----------------- Remodeling and/or repairing (describe):--- ------------•------ -------------------- ----- ---- - ------••------------- -----•-------- ---------------------- ---------------------------------------------------------------------- --- ... . _____________________________________________-_--_..._......_._._______--_____-__-_ �. ..___- __-_____....___ _ ____ `__-_._.__.._-...____-•_____-_______-__�__.__.___..___- I hereby certify that I have prepared this application and that the work will a done in accordance with San Joaquin County ordinances s, and rules an reguiat ns of t 9., an Joaqu' Local Hea h District. (Signed..1 - __*; - �__) !•� �_%Pl"\V �'' �-- -• �- --•----�---`-�----_`-------- Contractor Br-------•------------------------- ----------------.................----------------- •..... _ _.....:.......(rifle)--------- ----------- (Plot plan, showing size of lot, location of system in relatio o wells, buildi , etc., can be placed on reverse side). FOR EPARTMENT USE ONLY G APPLICATION ACCEPTED BY f DATE -r F� --------CP � REVIEWEDBY----------------------------------------- - ----------------------- ------------------ DATE----------•---- --- BUILDING PERMIT ISSUED------------------ --------------------------..------------ ---• ------------ DATE........___------------------- .... -------------------- Alterations and/or recommendations:------I�a-k---,drr. l3__c._ ..........................----------I-------------------------------------------------------------------------------------;e---------------- ----------------------------------------------------------------------- --.....-•--------....................................... ---------- --•---------------------------------------• -----------------------------------------------•.... ------------------ •--------•------•--- i FINAL INSPECTION BY:e/ C Date s�7 - 5^/' -� SAN JOAQUIN LOCAL HEALTH DISTRI 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 DEVISED 5-89 ZM 5-61 ATLAS