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7r FOR OFFICE USE: ti. ... A y � � ^: ,� i y ' _�_1-----_-q -3 APPLICATION FOR SANITATION PERMIT Permit No. 7.1....... ---------- ----------------- ----------------------------- (Complete in Duplicate) -711' /.. -----------------=---------------------------------- --- This Permit Expires 1 Year From Date Issued Date Issued .........:�.,7. 6 '7� 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. JOBADDRESS AND LOCATION .�� 1----�- -------- .---------------------------------------------------------------------------- -------- Owner's r- s Name....--.. ........ Address--.......!fo d.......... .� '��----f------- `' - .... k� �.......... - { Contractor's Name------------C�._ ................•---•----.......----..............----••--- Installation will serve: Residence ❑- Apartment House ❑ Commercial ❑ Trailer Court [) Motel ❑ Other ❑ { Number of living units; A._ Number of bedrooms _-2---_ Number of baths .-.L--- Lot size ---S:v x % I c>-------------------- _... _ Water Supply; Public system El- Community system ❑ Private ❑ Depth to Water Table .....--. ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe®" Hardpan ❑ Previous Application Made: llf yes,date____________________) No El-. New Construction: Yes ©-No ❑ FHA/VA: Yes ❑ No ❑ TYPE OF•INSTALLATION ,AND SPECIFICATIONS: I (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tank: Distance from nearest well-----------------Distance from foundation....................Material-------------------------------------- ❑ No. of compartments---------- ---------------Size--------------------------------Liquid depth-=---------------------- pati i Disposal Field: Distance from nearest well , .-Distance from foundation..../..!;)..........Distance to nearest lot line--- ........ (All ®" Number of lines--------------'<-------- Length of each line---------- �'-..--------..Width of trench.-----1=-�---------.-- S Type of filter material._w:—- ------Depth of filter material------L -----_-----Total length----------;�;?......:.........:.......... � Seepage Pit: Distance to nearest well--- /,, _p------Distance from f undation---- ------....Distance to nearest lot li�---_�_:--.---. Number of pits---------I------------Lining material---�'Q� -----Size: Diameter..--...: _3.., Depth_-��-------•- --..-. Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material--..--------------------.--:_------._El ' . Size: Diameter--------•--•--------------------------De th----------------------------------------------------Liquid Capacity _-gals. I Privy: Distance from nearest well---------------------------------------------_--Distance from nearest building...........-.--..--..-_-.-------.-...... ❑ Distance to nearest lot line------------------------------------------------------------------------------------••---•----------------------------------------:---------- '4 Remodeling and/or repairing (describe):---------------------------------------------------------------------------------------------------------------------------___-------------------- ----------- ----------------- ---------- --------------------------••---------------------------------------....---- ------•-----------------------•--•-----------------------.-...--------------------------------------------------------------------------------•--------------------.-.-.........-------...------------------------------------- I ....--------------------------------I hereby certify that I have prepared this application and that 4he work will be done in accordance with San Joaquin County ordinances, State laws, and rules and regulations of the San Joaquin Local Health District. (Signed Si ned-------------`.-?`t------------ ------- .... ------------------------•-----•------------{Owner and/or Co ntractor By:_ �----------------------------------- --------------------{Tit 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------------------------------------------------------------------------ f DATE---------- � j �----------- REVIEWEDBY---------------------------- ---- ----------- DATE------------------------------------------------------------ BUILDING PERMIT ISSUED---------------------------------------------------------------------------------- - ------- -..-. DATE ' Alterations and/or recom end' ions:; - -- r r r FINAL INSPECTION BY:. CA A -^ ------ Date--- ..--- . a " ------------------------------------------ SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Srroet 124 Sycamore Street 205 West 91h Street Stockton,California Lodl,California Manteca,California Tracy,California E5 9 REVISED e•59 2M 5.62 ATLAS - i