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FOR OFFIC� U$E: --------------------------------- ---- ._ APPLICATION FOR SANITATION PERMIT Permit No. .....1. •,C.1...� ----- q ---- -- --------------------- ------------------------- (Complete in Duplicate} Date Issued ---- ------------------------ ---------------------------------- 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 No. 549. 01 JOB ADDRESS AND LOCATION.---- ------------------/ - --- ..--- � ............................-------- Owner's Name---------------•----- sx l hh °r _... --------------------•---•--••---------_-. Phonet _ �� n Address................................................... .27. 49.---------------------- ---------._... •--------_--------------------------------------------------------- Contractor's Name_` __ �__ __._t..l! , s_ ` �� ' _t�G' Phone � ..... Installation will serve: Residence [�partment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ 'Other ❑ Number of living units: __ _. mber of bedrooms ---- 6 -�---- - -- ............. umber of baths ..:.___ Lot size __``_ .. Water Supply: Public system Community system ❑ Private ❑ Depth to Water Table" x..0 ft. Character of soil to a depth of 3 feet: Sand Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe 0--/Hardpan ❑ Previous Applicaflon Made: llf yes,date. 1. 1�No New Construction: Yes ❑ No ❑ FHA/VA: Yes ❑ No ❑ AND SPECIFI ATI0, `l TYPE OF INSTALLATION {No septic tank or cesspool permitted if public sewer is available within 200 feet.} Se T eek: Distance from nearest well-----------------Distance from foundation------------.__..-..Materia!________________--_----.-_-_.._-_-_---------__-:. No. of compartments--------•-----------------Size-----------------------•--------Liquid depth--------------------------Capacity---................... Mo a 'al ld: Distance from nearest well_144_4`l?.-Distance from foundation.-..D_"......Distance to nearest lot line------E?....... v l f Number of lines---------- ____. ____ _______._Length of each line___a __�'"_.�.__-..Width of trench.............-4__ _ ______..:.... 'j- A a� Type of filter materia 15-1-1& ��e Depth of filter material____.. Total length-----a�_,�!..........---------- f------- Seepage Pi``t: Distance to nearest well----------------------Distance from foundation----................Distance to nearest lot line__-____._______-- �1C,v Number of pits----------------------Lining material-----------------------Size: Diameter------------------------Dept h----------------...___----------- 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_____..--_---_______-___-________.__..-... ❑ -Distance to nearest lot line------------------------------------------------------------------................... -------------------•-----------•--•---------------- Remodeling and/or repairing (describe)-- --- --------•-- ------I------------- - ------ - .. �•----- -------------------- ------- u.... [ -•--- " = ``�j ' J -------••----------------------•----G"•____- --------- --------------------------- -------1-------- ------------------------ ----------.........__.. ..._.... ----------- 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 and regulations of the San Joaquin Local Health District. tom_ f Si ned .DIV �`T J.L'.. ? P" �: ---------- Contractor ; { BY: •-•------------------=------------------------ ------- �n , {Title) -.__..... (Plot plan, showing size of lot, location of system in relet n to wells, buifdc., can be placed on reverse side). FOR DEPARTMENT USE ONLY- APPLICATION ACCEPTED BY--- ==---- --- ------- -------- --_--•------------- DATE-..._?-- j 2 ` ---•---•--- •-------- I�EVIEWED BY--------------------------------------- ---------------------------------------_- ------------------------------------- DATE............................-----.... -----•-•-.-_-- $UILDING PERMIT ISSUED---- -- ------ -------•------------ -------------------•-------- .._...----------------_--' DATE---------- �`.. ------------------------ Alterations and/or recommendations:--------------- -------------------------- --------------•-----------------------•-------------------------••--•-•••--•------ -----------T----------------- .................................-------------------------------------•--------•--------•----------•-----------------------•----•----------I.........--•-----•-----------•-----------------•-_..----------••---•----------•-. 1 -------------•-------•-----------------------•---•-------------------------------•-----------------------------------------...-...------------_._..........------....----.....-•-•---•-----•-•---- ---------------••-- i FINAL INSPECTION BY:--- ==------- --------------- Data----- -- �__: ..-------•................... i SAN JOAQUIN LOCAL HEALTH DISTRICT * 130 South American Street 300 Wast Oak Strad 124 Sycamore Street 205 West 91h Street Stockton,California Lodi,California Manteca,California Tracy,California ES 9 REVISED B•89 2M 5-61 ATLAS r