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' FOR OFFICE USE: 0 f/ �s ""--------------- ----------------------------------- APPLICATION FOR SANITATION PERMIT Permit No. ./N-3__Lt ------------------ --------------------------------------- (Complete-- in_Duplicate) .-..-s. . ---------------- -------- ----- --- - - m-- E--- ""This I F -permit Ez fires i 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. This application is made in compliance with County Ordinance No. 549. JOB ADDRESS AND LOCA ON ----------- ' Owner's Name1--------- z�— ........---•--. / 1 'f G'�' ?..:---•-•--._-1`-_--------- Phone...... •------- ..� -- Address...............• _ i Contractor's Name_____._. I N-- -- - � •• 4:?"��..�'.r...�. _�.�.. .�✓�^---- ..._....... Phone Installation will serve:CResidence Apartment House ❑ Commercial ❑ Trailer Court E] Motel ❑ Other ❑ Number of living units: --_11- Number of bedrooms __/-__- Number of baths _/____ Lot size j----f /' �- T Water Supply: Public system ❑ 1 Community system ❑ Private Depth to Water Table4�ft. Character of soil to a depth of 3 feet: Sand Gravel Sand Lo P I ❑ ❑ y am ❑ Clay Loam ❑ Clay ❑ Adobe Hardpan ❑ Previous Application Made: (If yes,date___________________} No New Construction: Yes ❑ No FHA/VA: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) I Se Tank:- Distance from nearest well_________________Distance from foundation_______-....._..___.Material........................................... _..... � AIy No. of compartments-------- ------Size------------------- "--------_ -------------Liquid depth------: ------..._Capacity....................... �- fos�I Fie Distance"from nearest well_________________Distance from foundation.-----------------__Distance to nearest lot line................. �] Number of lines---------------vit`-----------._Length of each line------..---.--..------.-.-_-"Width oftrench................................... t �, Type of filter material.-----------•--- ..--Depthof filter material------�� ---Total length...................... ------------------•- See a ePit: Distance to net well____ ti Distance m foundation___ ...........Distance to nearest lot line 9 ------------ /Number 1l �� r, of pits---_..__----------___Lining materlal�_-A��s�_5ixe: Diameter. �,._ ._____._..Depth__ -_•_--__--- I tit � , Cesspool: Distance from nearest well...... ------- _---Distance from foundation__ ... material_-._-__...... .----------------------- ❑ Size: Diameteri--------------•----------`-----------Depth---- = --------`'V' ---Liquid Capacity---�----------------------gals. i - ! 1 s Privy: Distance from.nearest well________________________. � c° Distance from nearetst building ❑ lin-e- ----------------------- F Distance to nearest lot lir~ie'"w`�_"°__ --`--- - --�•-•-- Remodelg arid/ r repairing (descrlbe): ---- r t i ------ •---------------•- I hereby certify that I have prep application end-tha+ the work will be done in accardance with San Joaquin County ordinances, State laws, nd rules regulati s of the San Joaquin Local alth District. I Si ned l ( 9 --- _.,,,_(Owner and/or Contractor) i - i BY: .................. ---------- --- -------- - ------- -------(Title)--- p - (Piot plan, showing size of lot, location of system in relation t wells, buildi etc., can be pla6ed on reverse side). 1 57FOR DEPART ENJ U ONLY \N"-" APPLICATION ACCEPTED BY---- '= -- - -- ---- ------ --- ---------------------------------------- DATE-----/ VIEWEDBY---------------------------------------------------------- m-mDATE .......... BUILDING PERMIT ISSUED------ -... - DATE ---------------- -- i AFFe alio and/or recommendations: • -------------------------- -----•-----------------------...-•-----------------•-----------------------------•--- -------------•------------- .I i t �- --•- -. -- �- ---- - - ----------------------------------------------------- ------------------------------------ --- .........•. --------•--- •------------- ------------ -------- ---------------------------------------------- FINAL INSPECTION BY: l -------------- ----------- Date........ SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 124 Sycamore Street 205 West 9th Street " Stockton,California Lodl,California Manteca,California Tracy,California ES 9 REVISED 0-59 ItM 5-61 ATLAS