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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT Permit No. ...,1 ... ,?... -- - ----------------------------- ---=-------------------- (Complete in Duplicate) --------------------------------- - - - - This Permit Ex ices 1 Year From Date Issue Date Issue ............. Application is hereby made to the San Joaquin Local Health District for a permit to cons instal t e work h rel describe ' This application is made in compliance with County Ordinance No. 549. JOB ADDRESS AND LOCATI N__ ___. .. --- Owner's Name.. ...... 1 x ---------•----- -------------------------------------------------------------- Phone-------------------•................ c ti Address Qom' ��. .. -- ------ Ccs. _. - .............. �' - Contractor's Name....... a --•- -------------....... Phone-------••••---•-••......---------- Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: _7—._ Number of bedrooms _r__-..Number of baths.''____ Lot size .......... Water Supply: Public system ❑ Community system ❑ Private [V Depth to Water Table 1„r ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑Sandy Loam ❑ Clay Loam W Clay ❑ Adobe❑ Hardpan ❑ / Previous Application Made: (If yes,date--------------------) No New Construction: Yes No ❑ FHA/VA:Yes ❑ No ❑ f Ir TYPE OF INSTALLATION-AND SPECIFICATIONS: `A ' (No septic tank-or cesspool permitted-4-public-sewer'is'availeble within-2OO Septic Tank: Distance from nearest well___S'4.____--Distance from foundation----/__Q_.........Material------ ... ..... ............... 1 No. of compartments---------Z-----' =Size 1�-X--�'�°- ------.---Liquid depth-- =---- --------------Capacity___�>S' p + Disposal Field: Distance from nearest well..../9-4----Distance from foundation.....40_.-_.=__Distance to nearest lot-Iline__s:........ Number of lines-------_--_-.3-----------------Length of each line--------i_O_0--- �: ------.Width of trench...... -.----------------------- C r Type of filter material._..l -- -----Depth of filter material-----/.9.... Total length--------- d____________________ Seepage Pit: Distance to nearest well----------------------Distance from foundation--------------------Distance to nearest lot line__...______-___._ f, ❑ 'Number of pits-___________________Lining material-----------------------Size: Diameter_......................Depth_;A___________ !? Cesspool: Distance from nearest well_________________Distance from foundation._.__.______-__-__..Lining"material::J___ __ __.-.-.__::_.._.-...._.. ❑ Size: Diameter--------------------------------------Depth----------------------------------------------------Liquid Capacity----------------------------gals. Priv Distance from nearest well_____________________ --Distance from nearest building ________________-__. r ❑ Distance to nearest lot line----------------------------------------•--------•--------------------- ---------•-------- --- E Remodeling and/or repairing (describe)-------------------------------------------------------------------------------------------------------•-------•-----•-•----•--=--------•-----•-----••----- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ - ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County t ordinances, State laws, and rules and regulations of the San Joaquin Local Health District. \` (Signed}• -•---- --- ------ -------------------------------------------jCWm"w-vn4/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 APPLICATION ACCEPTED BY-- - ------------------------------------ --------------------------- DATE----.--X.--------- -�---------------------------- REVIEWEDBY----------------------------------------------------------------------------------------------------------------------------- DATE------------------------------------------------------------ BUILDING PERMIT ISSUED--------------------------------------------------------------—...................................... DATE----------------------------------------------_-------•---•- Alterations a /or r comm dation :-_.-_- ,. _ -___ -------•-------•-•-•- ------------------------------------------4__------------------------------------------------------------------------------------------------------------- -----••----------------•--------------- v ------•-•------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- FINAL INSPECTION BY '- . --- ---- -------------- 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 �'EB 9 REVISED B-B9 21A 6^61 ATLAS .;`