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FOR OFFICE USE: _ _________________________ ___ ___ APPLICATION FOR SANITATION PERMIT Permit No. .. i - ------------------------------------------------------- (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 compliance with County Ordinance No. 9. I JOB ADDRESS AN L C I N---- . .... 7--- --- --------- ----------------••---.... 7 Owners Name...._ ••---•-•-----------------•------ --- •------- -•---•-----•�J Phone /Z. Address -• ...•.-----• -- ---- - _ ----•--- _ ) -_. _ - •--- .. �... ..... .. Contractor's Name__...�....................... . .._.... s... . ---1--- ------ •--- Phone __¢_ Installation will serve: GResidence 1[f �partment blouse ❑ Comma al"❑'Trailer-Co'u'rt-❑—Motel ❑ Otherj❑ i d dI e Number of living units: .,-_ Number of bedrooms �_ Number of baths __. _ ,Lot size -1�Q...................... Water Supply: Publicsystem C3Community system ❑ Private Depth to Water Table ft. I Character of soil to a depth of 3 feet: Sand C] Gravel El Sandy Lo 6m Clay Lom ❑ Clay ❑; Adobe❑ Hardpan ❑ Previous Application Made: (if yes,date----------------<.-} No ❑ New Construction: Yet ❑ No HA/VA: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: o septic tank or cesspool permitted if public--sewor-is available within 200 feet,)' I , Distance from nearest well______j------- Distance fromrfoundation_______ --------Material---------._----_----.....-;...................... �. ❑ No.' of compartments---------- �+-----•--Size------------- Ii Liquid depth------------------- -----Capacity_..................... t Distance from nea st well__----�____._Distance from foundation_'__...._.Distance to nearest lot line__.._....... t Number of lines- I __-___Length of each Alin 0_1A.7'311-."Width of irench____.�� t Type of filter,amaterial.�1��°�---_Depth of fltarmafierial.�,$'�!_J_______Total lengrtlti_________________ -Q--•-----•••- t ) _.____.Distance from', _"Distance;to,nearest-lot',l ne................. Seep ge Pit: Distance to nearest well______________ n_ ' Number of its Lining material-----------------------Size: Diameter__r3...—_____...__.Depth--------------------------------- ❑ py .. Size: Diameter- Depth - .Liquid Capacitjr. , V •--•--- l • -- Cesspool: Distance from nearest well________________ Distance from foundation_ Linin matena_._ Distance ;from nearest well__________ _ __._._Distance from_rear•est building ___,-- --i -----------. Privy:� ---------------------------•--- ,'!� ❑ Distance to nearest lot line -------------------------------------------- r- '. �moelng and/or repiring-{describ ---------•----------------•----•-•------•---•---- -•-' -- _.. �....__.......------. -------Re ..... i ------•----------- ----------•-----------------------•----•--•---•--------------_•--------......------•-.--- i - ti V -------••--••-------- I - 1 ----••---------• -----•-`v- • - Y____________________________________________________________________________________________________________________________•-••==___._._ __ _. _.___________._ 1, ere certify that I have epared this application and that the work will�be done in accordance witty San Joaquin County ' ordinance t la nd r es d regulatio of the Joaquin Local Health District. (Signed) •---- t_ ---------------------------------- ner and/or Contractor) By: �_-. . -*.�{Title)= •==------- --- (Plot plan, showing size of lot, location of system in r i wells, buildings, etc., can be 4Placed on reverse side). t FOR DEPARTMENT USE ONLY r � ) APPLICATION ACCEPTED BY----------nF-1 0-------------------- _ ---------.------.......... DATE.... " ��- f� ...... REVIEWED BY--------------------------------------- ` ------------------- ------------------------------------------ -- -- ------•------ DATE BUILDINGPERMIT ISSUED------------ --------------------------------------------------------------------_ ----------- DATE-----.1------------------------------------------------------ Atteraiionsand/or recommendations:------------------------------------- --------------------------------------------------------------..............................-------•--------. -------- i ! --------------- --------- ---------•--•------------------------•------••--------••--------------------•-•-••------------•-------------------•---•-------------- ----•--------------------••- i --------•- •------------•----------• - --------------------- ....................... I ..............I............._....__... . ------ ----•-------- --- ----- -- FINAL INSPECTIO '--------------- - Date :..1-J__..-_ /�_r......................... SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Streef 124 Sycamore Street 205 west 9th street Stockton,California Lodi,California Manteca,California Tracy,California CS '9 REVISED B-89 RM 8-6t ATLAB r