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FOR OFFICE PSEV _ r � •— / r` APPLICATION FOR SANITATION PERMIT Permit No. ...l._ --------- ---------------- ---------------------- (Complete in Duplicate) � �3 - ---------------------------- ---------------- This Permit Ex ires 1 Year From Date Issued Date Issued ____ -----____... Application is hereby made to the San Joaquin Local Health District for a permit to constru t and in Ilk the work herein described. This application is made in compliance with County Ordinance No. 549. C� n JOB ADDRESS AND LOCATION _ _ .- ------ ----------------------- -------------------------------------- --------- ---�h-- �,- -------- ` Owner's Name....__,_&P.-..� --=---------------------------------------------- Phone....... "� Address------------T8lc� _ :._�_-•-�.__...----•----•-•--- ------------------------.....-------------------...-• Phone...................................- Contractor's Name--------- ... -------------------------- ------------------------------------------------ Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other El Number of living units: ...I--- Number of bedrooms Z. Number of baths Lot size -los6_41-k7l.____P___!.•••-•---•------- Water Supply: Public system Community system ❑ Private ❑ Depth To Water Table _4- ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ AdobdB Hardpan ❑ Previous Application Made: (if yes,date--- -.-------------- No [ New.Construction: Yes �o ❑ FHA/VA: Yes ❑ No 5 e I TYPE OF INSTALLATION AND SPECIFICATIONS;-- (No PECIFICATIONS:F(No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic,lank- Distance from nearest well___ -____:Distance from foundation--L-o___`_.._____.Material___2..2-c ---- u _____-____. No. of compartments_____,e2_--............Size__.._3__A4 --?._.Liquid depth__--'%-----------------Capacity____�b�'�•�� Disposal Field: i Distance from nearest well--f77�----------Distance from foundation,-49- __:_____.Distance to nearest lot line-------------_- Number cS ---_._.- Number of lines__________-2-l-------------------Length of each line-----;;"_jS.............._.Width of french._ __-__..._-_______ Q s Type of filter material._:777ta4%t------Depth of filter"material..___4,T_`-------Total length____ 010_`___________________ h+ I Seepage Pit: Distance to nearest well--_—---------Distanceaom foundation__ 0-----------Distance to nearest lot line____.-------- Linin material- -----fPL:E-_----Size: Diameter-3.3..._______.Depth_..-��---------------• Number of pits.. g Cesspool: Distance from nearest well--------_____----Distance from foundation--------------------Lining material-_.________.__-__-___________________ �^ ❑ Size: Biometer---------------- -- ------------•--Depth--------------------------------------------------_Liquid Capacity------------------------_--gals, VJ Privy: Distance from nearest well_________________________________________________Distance from nearest building__________________-.----_-______________. ❑ Distance to nearest lot line-------------------------------------------------------------•-----•----------------------------------------------------------------------- -- ---------••-•---•------------------------------------ Remodeling and/or epairing (descr- e):-------------- -- - ------- � -- -_�J _ ------•------------'-------------------------------••----•-------------------------------------•••-------------• -----------•-------- -----------------••------------------••------••---- —. I hereby certify that I have prepared this applicat' and th the work w' be done in accordance with San Joaquin County ordinances, State laws, and rules and regulations of a an Jo uin Local ealth District. (Signed)----------------------------------------- •------ -------------------- -- -------- -- - ---- -- ---- - ------------------ -------------------------------(Owner and/or Contractor) By:-----------------------•---------•----------------- ------ ----------- ---- ----------------- ---------------------------(Title)------------------------------ --------- ---.-- ------------- (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 _. 1lar �,at - DATE----------------------------------------•------------------- REVIEWEDBY-------------------------------- ---------- ------------------------------------------------------------------- DATE-------------------_____-------------------------------- BUILDINGPERMIT ISSUED-----------------------------------------------------------____---------------------------------- DATE------------------------------------------------------------- Alterations and/or recommendations: ----------------------------- ----------------------------------•-------------- ---------------------------------•••-• •-----•------------------ ---------- i ...................6-a- __ ----------------�---�.-- d _-_--------------------_I ---•------------------ ----------- -------------------- ------------- -- - �- ------------- ----- �y i FINAL INSPECTION BY:----------- ----------- ------------- Date------- -��-----��--�----�-�p--.3---------------•-- ----------------- j SAN JOAQUIN LOCAL HEALTH DISTRICT i 130 South American Street 300 West Oak Srreet 124 Sycamore Street 205 Wast 91h Street Stockton,California Lodi,California Manteca,California Tracy,California ES 9 REVISED 9-59 2M 5.62 ATLAS