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FOR OFFICE USE: -------------------------- ---------------- -------- _.,rtA► / ---------------- APPLICATION FOR SANITATION PERMIT Permit No. ...,C_f �_ ,1� -------------------------------- -------- (Complete in Duplicate) / -----.-.--- This Permit Expires 1 Year From Date Issued Date Issued ----- AA_ 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. 549.4 `Z� — 030 f.3 tl-7 6-,a AJ- 0-044A-C- rid JOB ADDRESS AND LOCATION- 'ri-/`� Owner's Name &� _------------------------ r ----------------------•-------------- ------ Phone..................... •---•--- Address 1 ---/---•----•. s---`} Contractor's Name.. 2----------------------- --------------------------- ------------------ Phone.. ------ Installation will serve: Residence 9 Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: ../-___ Number of bedrooms ---W_ Number of baths ---2-_ Lot size .._� J� L ., ---------------------------- Water Supply: Public system ❑ Community system.[] Private 6 Depth To Water Table Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe 6� Hardpan ❑ �,j Previous Application Made: (if yes,dote--------------------) No fX, 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.) Septic Tank: Distance from nearest well ___Distance from foundation___ �i ( �(" .._. -- ____....... P -- _ 1__._._..__...M/a�er ah r No. of compartments____?�_-._________Size__ Li uid de th__ -7` 'z�____--_Capacity -- q P. ._fd1r Dispo al Field: - Distance from nearest weli___ ._Q.._.Distance from foun n._ _l _......��D�i .ante to nearest lot line---- f 1 Number of lines_____-_______ ____________ Length of eRcci line_`______ � .4V idth of trench____-....-__'.1—_ ________.._ - ------------ T7 Type of filter material._._____ __ -- Depth of filter material____-- --_P_________.Total length---------3..21r 5_________________ Seepage Pit: Distance to nearest well----------------------Distance from foundation--------------------Distance to nearest lot line----------------- ❑ Number of pits.-.--------:---_---_--Lining material-----------------------Size: Diameter------------•----------Dept h------------_-_------._..------- � Cesspool: Distance from nearest well----------------_Distance from foundation--------------------Lining material___.___-____-_______--___-_______._._ d ❑ Size: Diameter-------------------------------------.Depth---------------------•------------------------------Liquid Capacity.--------------------------gals. Privy: Distance from nearest well------_-------------------------------------------Distance from nearest Ibuilding__.________.-__..__.._--._.___.__..______- ❑ Distance to nearest lot line-----------------------•----•-----------------------------------.......---•----------•----••-------------------------:._..------------------- Remodeling and/or repairing (describe)---------------- _!Lt .......------------------------------------------------------------------- --------.---- ----------------------•----------------------------- ------------------------------------------------------------------•--------•-----------------------------------------------•-----•-•----------------------------------- hereb certify t at I ha a prepared this applica+ion and that +he work will be done in accordance with San Joaquin County ordinances, ate law , r s and regulations of the San Joaquin Local Health District. (Signed) -------- ------------------(Owner and/or Contractor) By:----------------------------•-------------------------------------------------------------------------------------------------------(Ti+le).--•------------------------------------ - - - --- --------- (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----------------------- -------------------------------BY-------- DATE--- C�-------- BUILDING - �� BUILIDING PERMIT ISSUED------------------------------------------- — � DATE - -- -• --•------------------ Alterationsand/or recommendations------------------ ------------------- ----- ------ •--•----------------•--------_-------_--.----••-•---•-----------••----------------•-•---------------•---- ---•------------- ------------------------------------------ --------------------------------------- --------------------------------------------------------•--•------•-•-----------•----------------------------------- --------- ------------ ------------------- ------------------------------------------------ ------------- ----------------- ------ . •------------------------•--------- .............. -------- --------------------------------- ---------.-------------------------------------------•----------------------- J FINAL INSPECTION BY:.------ ------- Date---------------------------------- ---- •--------------------------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 124 Sycamore Street 205 West 91h Street Stockton,California Locil,California Manteca,California Tracy,California ES 9 REVISED a-59 2M 5-62 ATLAS