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FOR OFF! USE: Zk ¢. ...............----------------_ ___ .. . APPLICATION f PO)R SANITATION PERMIT Permit No. ..1.. ..... - --------------------- ---------- (Complete in Duplicate) -------------------------- --- This Permit Ex ires 1 Year From Date Issued Date Issued ---�7 ix �. 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 Ord' ce No. 5 JOB ADDRESS LOCA/TION•_.--•-- � � ---------• --- -----------------------------------------------•-•-•--.--- - ----------------- Owner's Name--- ---- ------- ------ •--I' " '= ----------- Phone------------:.._... ---------- t Address-----•-------- �`�p A �- ------- Contractor's Name Phone. 1 Installation will serve: Residence �partment House E] Commercial [-] Trailer Court [:] Motel ❑ Other 0 Number of living units: .__ Number of bedrooms _g;� Number of baths ./_. Lot size --. ...............:...:� Water Supply: Public;system Community system C] Private ❑ Depth to Water Table��. ft. { t Character of soil to a depth of 3 feet: Send ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe Ej—'Hbrdpan [] , Previous Application Made: (If yes,date--------------------I No E] New Construction: Yes [3No B FHA/VA`Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) to anh: Distance from nearest well__.......__`:..Distance from foundation___________________Material____------_-_-__-_---__._...:..........._.._..__. No. of � compartments-- - --_ -- -------Siie-----•--------------------------Liquid depth--------------------------Capacity...... r. Disposal F dr. Distance from nearest wel _ Distance from foundati n_�:5r....Distance to nearest lot line....S...r.... Number of lines_______/----. _- Length of each I'ne____ :_Q__ ------- _...Width of french.____^�� _�..�_------------- } Type of filter material...(__ k _j _Depth of filter material___. ----------Total length----------3.Q.... ------------------- Seepage .rt: Distance to nearest well_ --_____. ___Distan r m f9undation__,2.-,4_--r_..Distance to nearest lot line.___.S_-�_.._ Number of pits__________________Lining mater'a1 .L_( _-.Size: Diameter-___ ..... .___.Depth......, �►`___--_..._____...... Cesspool: Distance from nearest well-----------._._Distance from foundation--------------------Lining material•----_________________________________ !\ W ❑ Size: Diameter--------------------------------------Depth----------------------------------------------------Liquid Capacity_.---•--------------------gals. Privy: Distance from nearest well-- ________________________________.____._Distance from nearest building------------.____________•----.--.._-_-_. ❑ Distance to nearest !at line. . ----------------- --- 1 Remodeling and/or repairing (describe:- -' d- --------------------- ---------•---•--------------------------------------••• ------------------•-----•-----••------------------------------•--------- -------------------------------------- ----------.------------------------------------------------------------------------------------..-------- I here ce ify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances to laws, ��nr'ules an P regulations of the San Joaquin Local Health District. (Signed)...... .. --------- - ---------------- ..._ caner and/or Contractor) --------- --- By r .. {Title}. (Plot plan, showing sire of lot, location of syste in relation to walls dings, etc., can be placed o reverse side). I FOR DEPARTMEki USE ONLY APPLICATION ACCEPTED BY , -- `--`-------------------------------•---------------- DATE----�c -------- REVIEWED -----REVIEWED BY---------------------------------------� -------------------------------------------------------------------------------- DATE BUILDINGPERMIT ISSUED--------------------------------------------------------•----•---------------------------------------- DATE-------- ---------------------- Alterations and/or recomm ndations___________ ____.._______.._-._-.--_-..____ . V ----------- --- ------------------ --------------------------------------------------------------------------- ... - ---------------------------------------- ----------------------------------------------------------------------------------------------------=-------------------------------- ----------------------------------------- FINAL INSPECTION BY:...._.77 77 .-)- + c. x'-C.IX'`' -- Date------r � 3Z SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 Weft Oak Street 124 Sycamore Street 205 west 91h Street Stockton,California Lodi,California Manteca,California Tracy,California ES 9 REVISED 0-59 2Mr 8-61 ATLAS _ A