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y FOR OFFICE USE: X7APPLICATION FOR SANITATION PERMIT Permit No. :� . --------`-- ---------`�� - --Gz�d - (Complete in Duplicate) / - � ------- ---------- ------ .--.---.--..-.-..--..--- I This Permit Expires 1 Year From Date Issued Date Issued ill - 2., 0 - LfS- 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 co m liance with County Ordinance No. S49. -` JOB ADDRESS AND LOCrATION---••• f - - dt—_4---fold ------------- ------ =- Phone..---------------------------------- Owner's - .. - -------------- ------------------ Address------------........................................................---•-•-•-----•------- --------- -- . ..---.................•------------...------ --•-•-•----•---•--------.----- Contractor's Name....--• o. - S-f7.3f----------------------------------- .......------ ----- ---- Phone..-----............--------------- Installation will serve: Residence e Apartment House ❑ Commercial [❑ Trailer Court ❑ Motel ❑ Other [3 Number of living units: ___j--- Number of bedrooms _- -- Number of baths ._j---- Lot size ------X-0 A.Ifs:C?--------------------------------- Water Supply: Public system E] Community system �;vate ❑ Depth To Water Table -ST ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam [ lay ❑ Adobe ❑ Hardpan ❑ t Previous Application Made: (If yes,date------_-..---.----) No { New Construction: Yes Ekl o ❑ FHA/VA: Yes Po"'No ❑ i TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool peimitted if public sewer is available within 200 feet.) 1 -- Septi �ank: � NoDist of compartmentsance from t well-----------------Distance from foundati�lquid depth_-Material.---:---Capacity----------------------- jf Disposal eonearest well ---- Distance Distance to nearest lot line__--____---•..._ 9 11 Numbeof lines - --Lth of each line --.-.---..Widthfrench f (� offrench-------------------------------.--- '- + Q Type of filter material-----------------------Depth of filter material-----------------------Total length--------.--__.................r--------- �. i Seepage Pit: Distance to nearest well---- 1�'-Q-.--.-_.Distance from foundation.1Q---_-.-----.Dist nce to nearest lot liner--.----_--_ Number of pits----I----------------Lining material`'-4.k-Size: Diameter-_- .r Depth------ _«4'j.-----------_--_ a� Cesspool: Distance from nearest well-----------------Distance from foundation-------------------.Lining material_------....._----------------------_- ❑ Size: Diameter.----1- •-----------------------------Depth----------------------------------------------------Liquid Capacity-------------------------...gals. Privy: Distance from nearest well----------------------------------------- -------Distance from nearest building------.-------------.-_-.--___-_.-.----.-. ❑ Distance to nearest lot line--- ------------------------------------ ----------------------------- -------------------------------------------------------- ------ Remodeling and/or repairing {describe):-----�------ w -------6 ..f�� ._� Z ! --_--.GZ.'"- ----.-------------------------------------------------------- I ...----•--------------•-----------------....----------------------------•----------------------- -----------------------------•-•---------------------•-----------------------•------- ------------------------------------------------•------------.........-__-----•-----------•----------------------- I hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State laws, and rules and regulations of the San Joaquin Local Health District: (Signed) --------------------------Owner and/or Contractor BY= - ---- -- ---- -------- ---------------------------------------{Title) (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY---- -- ------------------------------------ DATE----- REVIEWEDBY------------------•------------------� l -------------------------------------------•-----........................-• DATE-------------------------------------------------------- BUILDING PERMIT ISSUED---•-•-••--. ------ -----------------------------------------------•---••-......... DATE------------------------------ ------------------- ,Ahterations an4/or recommendations----------------------------------------------- ----------------------------------------------------•-•-----...-•-..........-..-..-•-----•--••---------------- `7 r(i f - ---F ---------------- -------------------------------------------------•---------------------------------- FINAL INSPECTION BY: Date------ ------------------------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 Weil Oak Str�il 114 Sycamore Street 205 West 9th Street Stocktonr California Lodir California Manteca,California Tracy,California ES 9 REVISED 8-59 2M 5-6d ATLAS 111+ ��1