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FOR OFF,I,C USE/ 111' _ _---.--_-_----�---------- -------_.----. --I�. APPLICATION FOR SANITATION PERMIT Permit No. _-./.��.. (Complefe in Duplicate) ----------------------- ------------------------ -- •---- // ----------------------------- This Permit Ex fres 1 Year From Date Issued Date issued ... .L 71. tzi Application is hereby made�lo 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. 549. t JOB ADDRESS AND LOC IITION ----- ..... I. Clie Inte-A-v : }� Owners Name----------------------- ---- - --------------------------..--------------------- Phone.-.. !'`Q. :n.1?&o Address_ ' �i Contractor's Name...-..•-•--- - ---------�'b�1't� Installation will serve: Residencekg Aparfinen�;,�-•...-•-•--.---------....--------------..__----------------•----------•-•-•-•------ Phone................................... t House ❑ :Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living unit': ...,-_,Number of bedrooms -: . Number of baths _..7. Lot size ----------- --�!-. ---------------------- . t t Water Supply: Public syst n ❑ Community,system ❑ Private)n Depth to Water Table "ft. Character of soil to a depth of 3 feet:t,Sand ❑ Gravel ❑I Sandy Loam M Clay Loam ❑ Clay ❑ Adobe❑ Hardpan ❑ Previous Application Mader (If yes,date---------- -----.---} No !71 New Construction: Yes ❑ No E] FHA/VA: Yes El No [I. .. A TYPE OF INSTALLATION AND SPECIFICATIONS: i (No septic tank or cesspool permitted if public sewer is available within 200 feet.) t f Septic Tank: Distance'Ifrom nearest well _.?f�...---.Distant ro f dation-_-_--.Q-.--.---.Material---------�1-.-----_ .......... P f / No, of compartments----.---_ - -. _-_..-Size___f.�-:�X__.Liquid depth----------Ll----------Capacity..../__-3.,,r�-.0.. Disposal Field: Distance: from nearest well,* --------Distance from foundation-------:_.fp!�.Distance to nearest lot line..... Number.lof lines----------- ----------Length of each line----------- --�----. fh of trench.--------..- ................. T e of filter material YP ��' -- _-Depth of filter materlal�.-_s_ p� dial length---------- ..-----•-•-- fSeepage Pit: Distant e;to nearest well----------- ---------Distance from foundation....................Distance to nearest lot line------------------- ! :' t ❑ Number�of pits----------------------Lining material-----------------------Size: Diameter----------•-------------Depth----------•-•-••-•-------------•- Cesspool: Distancd1from nearest well'----------------Distance from foundation--------------..-_-lining material..................................... ❑' Size: Diameter. Depth Liquid Capacity---------_-•--------------gals. Privy: Distanca�'from nearest well----------------------------------.--------------Distance from nearest building--------_--_-_----_-.-_____.--------.--.-. Distanceto nearest lot line----------------------=-------------- ---------------------------------—----------------------- ---••-------------------------•------ Remodeling and/or repairing (describe)-------------------------------------------------------------•---_ - •---------------------- ,.. k I. ----------------•------x s , t I --••----------••------- -----------•-•--•--------•-•-----------------------......................_. ----------•----•----------- -------- I hereby certify that I :rave prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State laws, and rules and regul tions of the San Jaaquiri Local Health District. { g )-----•-•-... -p-� - � ----------------{Owner and/or Contractor) $y:------------------ �;--------------------•-•------------------------------------•-------------------------------------•-(Title)-------------------------------------------- - ------ (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). f } FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED,BY--- . - -- ---------------------------------------------- DATE------ �----------------- REVIEWED BY-------- ..-------------------------------- . -�M- ---------- - --- ---------------- ---•--------- ---------------------------•---------------- DATE--------•-- BUILDINGPERMIT ISSUED-t------•--•----------------------------•-•-••------------------------------•----------------------- DATE---•---------- Alterations and/or recomme l�dafions:..----------------------------------------------------------------------------•-- =....-•- --- E a f L . . I FINAL INSPECTION BY:.q...'---- --- - - --• --------- --------------------------- Date-- 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 B-59 ZM 6-61 ATLAS I J