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FOR OFFICE USE: ------ F --�� . APPLICATION FOR SANITATION PERMIT Permit No. ... .. �.�_. c�-" ----•--•- ---- -- (Complete in Duplicate} -------------•- ------•----- Date Issued -----------,....(.7/ -----------------------------------___------------------ This Permit Expires 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 Ordinance N 549. �J `� ----- JOB ADDRESS AND LOCATION--- ---------/a°-_�_I�----------1 re.)I_Gt -- -- --�1• --'_--------- f j Owner's Name ' .t �Cl�iO----•--•---- - ----•--------:.:_...: -_----------- Address -__-_-__= - - =_•. Address-----------------•--------' ........I----------- ............... f,---------------------------------------------••-•••••---••••---• If Contractors Name..-------•---•----•-AP.W*4�-1�^.---••-------•-•----------------------------------•--------••--•-••---------•---.:_. Phone...... h'?. � Installation will serve: Residence Apartment House ❑ Commercial ❑ Trai) Court ❑ Motel ❑ �/Otherr�❑ Number of living units: Number of bedrooms .. Number of baths !r Lot size ___.--___�P__�1_..../,9.0......... :_. Water Supply: Public system ❑ Com-muriity'systern Private❑. Depth to Weter Table____- ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel C] Sandy Loam ❑ Clay Loam Clay ❑ Adobe❑ Hardpan ❑ Previou-s'Application,Made: (If yes,dafe-----_--------______) No ❑—New-Construction:-Yes-[3 No ❑ FHA/1/A: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: f t : (No-septic tank-or cesspool ptirmitted if public sewer is available within,200 feet.) Septic Tank: Distance from nearest well__"_____________Distance from founds ion._.: . ._____ Materiel:'_______,_____.___..__.._...............__...... ' o. of compar#mens-----------------------•-Size----....-- -------------------:Liquid`depth------------------------ Capacity apacity• •-•-•-.....f. I Disposal field: Distance from nearest ell-_-- -____cDis+ante from foundation_) w Dis#ance,Rto nearest�.' T lke..5......... t Number of lines______ Length of each-line= __ • "`�' ;�:�:............Width of trench.----q*e , Type of filterrnaterial.- i� i-f4� Depth of filter material,`=__� _�j_____.__Total length_-�...-_... �..'______________ "V SeepreDistance lo nearest well______________________Distance from foundation....................Distance to nearest lot line................. W ❑ Number of pits_______ _____________Lining material--------------------.._Size: Diameter--------.-.----------- Depth................................. � I {._. �I , Cesspool: Distance from nearest well_________________Distance from foundation.....................Lining material..................................... Size: Diameter-------- -------------- ---_De th-.-------------------'------------ Liquid Capacity .....gals. Privy: DistbnceJeo-m_nearest well-_--____-•______ __________•________._-_-_-_____Distance'from nearest building,_...._............................._____. ❑ •Distance to i nearest;lot line-----------------`----------------=---------------- -----------•------• --------.---------------................... ........... Remodeling and/or repair ng 1(de r- e)--------------- --------- - ----------- ----------- ----------- ------- - ---------- --_----- ----- .4 .................. . ........:............... .......... ...................................................................... .............. ....... . ................ ........ I hereby certify that I have prepared this application and that the work will be dose in accordance with San Joaquin County ordinances State laws, and rules an ulations he!San Joaquin Local Health District. (Signed) f - =' r -------(Owner and/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 O LY ! APPLICATION ACCEPTED BY--------------- ----------- ---------- -------------- ... DATE........'� -- r--- ••------•---- REVIEWEDBY----------------------------........ s --------------------- ------------- /------------------------ DATE-_----•---•-----_I-•----------------------------------- BUILDINGPERMIT ISSUED------------•------ r...........----------------------------'-...................................... DATE -----------------------•---- -- Alterations and/or.recommendations:. ..... = _. `- - -- - _ ----== ==::_:�:----Y`T�; : ............ ...............................•---------------------------------------------------------------------------------------------------- ...--•••---•----------- `,1 Xa U "1�It f± 3 -----------------------------•--•- ;....---------•------•------._.-:.-----------••----• -------•------------------•---------------•-------------------------------------:--• -----•---------------•-•-------------_--� •----•-•------------•-••----------------------•--.--_------•---•--•-----------------•-------------------------------•-- ------- ----------------------------------------------------------------------------------------------------------------------------- FINAL INSPECTION BY:----- ,---------- -1- :---• i Date- ----------- 9-` -�--------------------------- 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 E8 9 REVISED B-89 4M 5-61 ATLAS - J