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FOR OFFICE SE: y -v V----- ----- ----------------------- -------------------------------------- ----------------- APPLICATION FOR SANITATION PERMIT Permit No. -. . ----------------------------------------------- --------- (Complete in Duplicate) �� //_3 -------------- This Permit Expires t Year From Date Issued Date Issued _____ ' 1 _____ , 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. JOB ADDRESS AND LOCATION_/ --- .- ------=�"`--.---_ -•--------- Owner's Name----- L .............-------------------------------- -•------------------------- ------------------------------- _ Phone........•........................... Address.------.-•-••----.1.17- Contractor's .Contractor's Name._.__ ._. ---------------------------•------ •------------------------------------------------ Phone----------------------------------- Installation will serve: Residence [Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: ____3___ Number of bedrooms _ __. Number of baths... Lot size .."fO._e4c'-A- -------________________________ Water Supply: Public system ❑ Community system ❑ Private [Depth To Water Table 1.8ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel.❑ Sandy Loam ❑ Clay Loam Clay ❑ Adobe❑ Hardpan ❑ Previous Application Made: {If yes,date--------------------) No B'_"New Construction: Yes ff`__N o ❑ FHA/VA: Yes ❑ No [�J ' TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) r f Septic Tank: Distance from nearest well---�_VO_--..Distance from foundation.j.4-----------Material__ _____________ - No. of coi apartments_.___-k----------------Size__S�f'-�r t�1!_ {_ _�Li uid de th____Y..e_.___.___ 1Z Disposal Field: Distance from nearest w II_�$p_-.---._Distance from founclation_10............Distance to nearest lot line_____ ..... [ Length of each line....: trench.---,__j� Number of-lines.-------- ------ -------•- 9 �0---•---•---•----.Width of -----------------•-•---_... Type of filter materiaI777ZaC:-----------Depth of filter material,/ -_______________Total length ------------------------ Seepage Pit: Distance to nearest well----------------------Distance from foundation--------------------Distance to nearest lot line................. ❑ Number of pits----------------------Lining material-----------------------Size: Diameter__-.-_--------------.Depth---------.---_._......--------. Cesspool: Distance from nearest well-----------------Distance from foundation---------------EFr_.Lining material------------------------------------- r_1 Size: Diameter--------------------------------------Depth--------------------------------------------------- Liquid Capacity—. Privy: Distance from nearest well-________________________________________ _______Distance from nearest building________._...--..-_------________.._.-.._. ❑ Distance to nearest lot line--------------------------------------------------------------------------------------------------------------------------------....--- Remodeling and/or repairing (describe):---------------------- --------------------------•---•-----------------------------•-••-=----•------------------- .........................----------• , _____________________________________....___-------_-----------_____-____-__.______________....._____._-__-_..__.______________________-___--_.._-_,_-_-_-__________--.-._______....________._-____---..-_____-______-..__-_ + i ..__________________________-..._________.-___-____.___________--______---___-___--_._ I hereby certify that I have prepared this ap' lication and that the work will be done in accordance with San Joaquin County ordinances, State laws, and rules and regulatio of a San J aquin Local Health District. (Signed)--------------------------------------------- .---•- - ---------------------•------------------------------------------------(Owner and/or Contractor) By:------------------------------------------ ••- ------ ----- ------•----------- ------------------------------------------------(Tale)------------------------------------------...... --- --------- (Piot plan, showing size of lot, location of system in relati n to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION! ACCEPTED BY___ / —� --�----- - --- ��---- -- ---------------•------------------------ DATE_...- _�L_� ,�— REVEEWEDBY --- -------------------------------------------------------------------•-------. DATE------------------------------------------------........... BUILDING PERMIT ISSUED-------------------- ---- ---- - -------- TE-- ------------------------------------------------- - -- Alterations and/or recommendation -------- -------------•----•----_--- ----•--------------------------•---------------.-...--••------------•--•.--•----------------------------------•-------------------------•-----------•----- --..._..._...--•-------------••---------------------------------••- -------•-----•-------------- ------------ ---------------I-------------------------- ----------•---.-..-------------•----------•------------------------ FINAL INSPECTION BY:- ------ ------- 1 -- - --T -------- ----- Date_ SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street '300 West Oak Street 124 Sycamore$frost 205 West 9th Street Stockton,California Lodi,California Manteca,California Tracy,California ES 9 REVISED 8-59 2M 5-62 ATLAS