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FOR OFFICE USE: __. -_ _____________ APPLICATION FOR SANITATION PERMIT Permit No. S.f --------------------------------------------------------- (Complete in Duplicate) ----------- This Permit Expires 1 Year From Date Issued Date Issued ...��.r../.. :.. . 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. 1. JOB ADDRESS AND ` CC�ATION...... _- ------ - --==----------- -----------•--•------•--...._...-..-----------------_-- Owner's Name, + :- = < -------------------------------------------------------- ---------------------------------------------- Phone.----------------------------•-•-. ----------------------------------------------------------------------------------- + Address--------------9,/ _. Contractor's Name ... ------------ Phone ' Installation will serve: Residence _Apartment House ❑ Commercial [] Trailer Court ❑ Motel ❑ Other ❑ Number of living units: __I-___ Number of bedrooms _3--- Number of baths J___ Lot size -----71_3._4y_X__?_.�_;�?_,................. Water Supply: Public system 1Zr__Community system ❑ Private ❑ Depth To Water Table _40_ ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe [Hardpan ❑ Previous Application Made: (if yes,date--------------------I No R3 New Construction: Yes ®'No ❑ FHANA. Yes ❑ No [?i-- TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) f Septic Tank: Distance from nearest well-�-T--------Distance from foundation___-KO_!........Material--------------------------------------- M' No. of compartments____�---------------Size.... ---------Liquid depth----1f_`---------------Capacity...k-G?-4T _.V-( Disposal Field: Distance from nearest we1L_O�......Distance from foundation'-/O...............Distance to nearest lot line._s`_/_---.- [�' Number of lines-----------------------------_-•---Length of each line----------------------........Width of trench._4S�__`--------------------- Type of filter material?4C.-(_.---------Depth of filter material.../.K'_"---------Total length._./ .-------------------------- Seepage f______________________Seepage Pit: Distance to nearest well./sQ_f-----------Distance from foundation__/..o....... ."'..Distance fo nearest lot line__•>- E3- -___- - I( L`Ja Number pits-_---Z-------------Lining materlaL�_��C_�('__----Size: Diameter---��-ry..---.--•---Depth__..�--J�----f••-----...------ 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 {describel:--f--------------------------------------•--•--------------------•-----------------------------•------------------ ------•------_-_-•---------- ------------------------------------------------------------------------------------------------------------------- -----------------•------•---------••-----------•--•--------------•------------.---------------•------------ ---------------•-------------------- ----------------------••------------•---------------- ----------------•-----•--•-------------••----•---------------------•-----------•------------••---------------------------------- 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 regulafi/of San Joaquin Local Health District. (Signed)---------- =-----•-�---- ----... ------•-----------------(Owner and/or Contractorl By-`----------------------------------------------------------- ----•----- {Title) -----=------- (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). i FOR REPARTMENT USE ONLY APPLICATION ACCEPTED BY--- - — ------ ---------------------------------------•--- DATE_._J__ ---- REVIEWEDBY---------- •-------------=`------------------- -------------- •---------------------------- DATE------------------------------- BUILDINGPERMIT ISSUED---------------------------•---------------------------------—-------- ------ DATE----------•-------------------------------------------------- Alterations and/or recommend' ions:.----------------------- ------------------------------------- ------- ------------------ ----- 3---`�--$-`�'- --�-----`---�' ----=-- -- --- - - - --- - --------- � __..fir. - ----- •• - - ' --------------- .�_..... ....... __.-. ...... I�............. .._ .------- :�� ------------------------------ q( G 7{�'E o G C� /lO.w.iQ - ? RNAL INSPECTION BY:----- 1,y .......... 'V7 Date--- ------1__�y=-----/T< I �A� UIN LOCAL HEALTH DIcFRICT —744 Syc*m''ore Sfre*1 205 West 9th Street Stockton,California Lodi,Ca ornia ! Manteca,Californlo Tracy,California ` E5 9 REVISED 8.59 2M 5-62 ATLAS l- F