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�FORFFICE PSE: _I_�_�c�_ -�3- APPLICATION 1=OR SANITATION PERMIT Permit Na. 4_ �r� -------------1-7 -------------------------------------- (Complete in Duplicate) Date Issued _------------------------------------ -- This Permit Expires 1 Year From Date Issued .._.._.1.........___ k Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described. F This application is made in compliance with County Ordinanc No. 549. JOB ADDRESS AND LOCATION_.... f__.. ____._._ _. Owner's NameIli - Phone... Address------------------ =&_&.f..---•-- ---- Contractor's Name........ . .. s 7 S Phone............... Installation will serve: Residence ❑ Apartment House ❑ Commercial ❑ Trailer Court [;- Motel ❑ Other ❑ Number of living units: ________ Number of bedrooms -------- Number of baths ........ Lot size __ _ �n.(`______________________________________ Water Supply: Public system ❑ Community system ❑ Private El'IDepth To Water Table 60 ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe�ardpan ❑ l Previous Application Made: (if yes,date-----------.--------I No New Construction: Yes a?-<o ❑ FHA/VA: Yes ❑ No TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) i Septi Tangy If Distance from nearest well-----------------Distance from foundation-------------------Material______.._____..-____---..__..-.-.___.._____-__--. ` No. of compartments--------------------------Size--------------------------------Liquid depth---------------- ---------Capacity---_------•-------•- Disp sal Distance from nearest well_,-3A2_______Distance from foundationiS"o-----------Distance to nearest lot line..s....... Number of lines.....I___________________ Length of each line__� ___ p_Z--.____________-.Width of trench.__, / Q Type of filter moferial–. ;�D4..A_________Depth of filter material---t4_*------------Total length----- Q.'___________________________ Seepage Pit: Distance to nearest well.3.60-------------Distance from foundation ......_..._-.Distance to nearest lot line_S j------- - �� Number of pits------- Lining material�J P4A-------Size: Diameter---(':___---------_Depth---0-__-- '___________-- Cesspool: Distance from nearest well_________________Distance from foundation------------------- Lining material___.__._.-_.-__--_-------___ ❑ Size: Diameter--------------------------------------Depth---------------------------•-----------------------Liquid Capacity-----------------•-..__....gals. Priv Distance from nearest well_________________________ _ __._Distance from nearest building ❑ Distance to nearest lot line-------------------------------------------------------------•-------.-•------------------------ ---------- I Remodeling and/or repairing (describe)-------------- ------------•------------------------•----•---•-•---------------------------------------------•---------------•---------•---- ----------•- ----- ------------------------•------_--...--•---•------------------------ ------•----•---•----------------•------•-------------------••••------------------------------•----••-•-•-••---------------------------------••--•-------••--•-------------•---------------•--•-••-----------•------------ I hereby certify that I have prepared his #01ication and that the work will be done in accordance with San Joaquin County i ordinances, State laws, and rules and reg aft s of th San Joaquin Local Health District. r (Signed)------------------------------------Z�� ------------ --- I-- - - ------------------------------------------------------------------------------------(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 ' - ----- ------------------------------------- DATE... — �---------------- APPLICATION ACCEPTED BY 0' REVIEWED BY------------------------------------------ -------------------- .�-------------------------------------. DATE----------------------------------------------------------- ----------------------- BU1!_DING PERMIT ISSUED_.. --------------------------------------•---------------------------------------- DATE-------------------------------------------------•---------- i A)t rations and/or recomme d'ations:-_.______________.-- a---------_.__-- ------------ " FINAL INSPECTION BY:------. ~, Date-------- f ----- ----------------- AN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 114 sycamore Street 405 West 91h Street Stockton,California Lodi,California Manteca,California Tracy,California ES 9 REVISED 8-59 2M 5-62 ATLAS