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FOR OFF1 E U E: ---- ` � IG _ -------- -------- APPLICATION FOR SANITATION PERMIT Permit No. ...f- G•• - (Complete in Duplicate) Date Issued ---- -------------- --- i 6 -..6. -----------------_---._._._--------.______--.-.--- This Permit Ex ires 1,.Year From 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 Ordinanc o 549. JOB ADDRESS AND LO ION....-L--�--- ---5 . .............................. Owners Name------------ -- - --•----•----• -- --- --��--------•-•-------------- ----------------- ----------------••-------------- ---- Phone.............•...................... i Address................................•-• ` . '- . —---------------------- Contractor's Name. L ( I Phone .. Installation will serve: Residence artment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of baths -_).__.Lot size ------- _Q-1- �• ----------•-••-- Number of living units: __�... Number of bedrooms - Water Supply: Public system �ommunity system [I Private ❑ Depth To Water Table ./ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel [3 Sandy Loam El Clay Loam ❑ Clay ❑ Adobelardpan ❑ Previous Application Made: (If yes,date---.------- No Construction: Yes ❑ No [a/FITA/VA: Yes ❑ No ❑� TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is,-available within 200 feet.) �.. Septic T;snk; Distance from 1� m ance from foundation--------------------Material------------------------------------------------- 1`� No. of compartments nearest well---------------rtments_________________________-_-Size__Dista'----------•-----------------Liquid depth-...----------------------Capacity_-..------------------ Disposal Reo.: Distance from nearest well-----------------Distance from foundation--------------------Distance to nearest lot line-------------.--- 4*D764if Number of lines-•----------•----------------------Length of each line----------------_----------.Width of trench----------------------------------- C>0 Type of filter material-_---------------------Depth of filter material-------_-__-------_-.-Total length----------------------- --------..-----•-- fnce to Distance f om foundation_._._ .. __y- / Distance to nearest lot line............ V' Seepage N�umaberr of ptnearest res/ell-_- -- Lining material.,/ �, -/e� .--Size: Diameter____!,�J��---_..Dept h_A_t�..................... Ud � F Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material---------------------.--------------- ❑ Size: Diameter----------------------------•---------Depth---------------- --------•-------------------------Liquid Capacity----------------------------gals. Privy: Distance from nearest well--------------------------------------------------Distance from nearest building------------------------------------------ ClDistance to nearest lot line �'o------------------------------------------------------------------------------------------------------- Remodeling and/or repairing (describe):----------------------- - -- ----------------� ----------------....----....................................... ------------------------------------------------------------------------------------ ••-------------•-------------•----------------------------•--•--------------------•--••------------- ------•----------•-----------------------------------•- --••------------------•-----------•--------------•------------------------------------------------•------• --------------------t----------------------- I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State laws, and rules al regulations of the San Joaquin Local Health District. -- --- Contractor) �� I (Signed) ----- ----------- ------- -----tion of - stem in relaf-- to:wells, -----••[Title] 1 � ---------- . .. -------------- (Plot plan, showing size of lot, Iota y buildings, etc:, can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY----- --------- -- -- _ --- -------------------------------------- DATE -.--/f'-t7--- ---4------3------------------------------- - REVIEW1D -- 3-------------- REVIEWED BY--------------•--------- -- ------------------- ------------------ -_ -------------------------------------. DATE------------------------------ ---------------------------- . BUILDING PERMIT ISSUED-----------------------•-----------------------------------------------•------ DATE.. - AFterations and/or recom enons:------------------------ ---------------------•---- e ---------------------------- -- --------------------------------------------------- ----------- -------------------------- FINAL INSPECTION BY:....__ _ ..._.._ Date----- cS,, -- -------------------- .V 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 E5 9 REVISED 8.59 2M 5-62 ATLAS