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FOR FFIC U . r z. f 3 � • o ' n APPLICATION FOR SANITATION PERMIT Permit No. .. ........... ...... / ----- ____________________________ _ _ (Complete in Duplicate) , ] I This Permit Expires 1 Year From Date Issued Date Issued --- ... Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described. ` Tlis application is made in compliance with County Ordinance No. 549. JOB ADDRESS A D LOCATION.. -___,_S �r-� ---•-------------------------••--------------- Owner's Name.-------;�1��.9� --•------- --- =--- -- --- ------ .------------------------------ Phone.7-w, ----- Address.-------------- --Address--------------- .. ..... -= C ---- ---------- ----------------•-•------ ---------...------------------ ---------- / .r��, f .._.�?- Contractor's Name^: - �- -- Phone = Installation will serve: Residence Qj/f{partm House ❑ Commercial ❑ railer Court ❑ Motel ❑ Other ❑ Number of living units: _"YN er of bedroola ____ Number of baths ---7"Cot size .____�— ____.7 Wafer Supply: Public system Community system ❑ Private ❑ Depth To Water Table ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ dobe Hardpan C]Previous Application Made: (If yes,date--------------------) No El New Construction: Yes ❑ No FHA/VA: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank sPm permitted fp�bliC sewer le ? 0 feet.) _ M terial___Se Distance from nearest wai ! txDistancefmfoundao • ___________________ No. of compartments-.-- -------- ----- Ca aci t_Y..•.-.•.rc Disposal Field: Distance from ne st well.14 .-Dista^Ze froim ..-Q------•• foundation.___�.®_._...D)stance to nearest lot line............. Number of lines_. Length of each line '-_4_�'/XWldth of trench___p`�,.. ��-- Type of filter materia _Depth of filter material--- length-------------------- �..-. 0- -Distance to nearest lot line--------- Seepage P' . Distance to nearest well�„rVV J____Distance,4rom foundation..__/.. Number;of Its_ Linin material_____________ ________Size: Diameter_-,3JA_-,3 Depth__-___ ..------ ---- a P � 9 t�k Cesspool: Distance'from nearest well-----------------Distance fro oundation_._._______--______.Lining material..___._______-._______..._-;______- ❑ Size: Diameter-------------------------------------Depth--------------;-------------------------------------Liquid Capacity gals. p Privy: Distance from nearest well------------------------------------------------Distance from nearest building-------.--.-------------------------....-. (' ❑ Distance to nearest lot Ii ------------------- ---------------------------•--------------•--------....-----------------------•--------------------...--•-------•-------- j -Remodeling and/or repairing (describe):---- -- ------•--- ---------------------- -------• --- -•-•---------------------••-----•------- ----•--••-----------•--------------- -----------••---------------•-•--------------------------------..._... + ----------------- -------------------------------------------- --•---------------------•------ --•... ----- --- - -- ... .-••-----. ----------------------------------------•---•-----•----------------- ---------- ------ O hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State la s, a d rules and regulations of the San Joaquin Local Health District. . /� _. (Signed)------ - - ----- -•--a _ cll�,.{--- -- ----•---------...----------- -------( for Contractor) s- By----------------------•----•--------- ------------------- ----------------- ------ ^1-'1----- --- ----(Title)-------------------------------------------- - ---------------- (Plot plan, showing size of lot, location of system in relation wells, buildings, etc. can be placed on reverse side). I FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY---------� _.cc< -------=---------------- -- ------ DATE------- ----------------.-.-- ' REVIEWED BY------------------ -------------- ---------------------------------------------.-.- DATE-----------•----------------------------•----------•---•---- BUILDINGPERMIT ISSUED----•--------------------------------------------------------- •---------------------------- DATE------------------------------------------------------------- Alterationsand/or recommendations--------------------------- -•------------------ ---------------------------------------------------------------.---------------------------------------------- 1 d' ----- +� 1 ------ - ---- PK�11�0 -------•----- 'rte ' --------- �1i ._ ,cc .. _ .... ' '° ---4 - .1 - --------------- ---------------------------------------•-------------------------------._... j ---•-•---------------------•----------------- r ---------------------------------------0.41-Y, -------------- ---•------------------ ------------------- ----------------- FINAL INSPECTION BY:........ ...---...-.__...---- - - G _ --------- Date ------- - .-------------------------------------- ---'-�c.� - 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 8-59 2M 5-62 ATLAS ;