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FOR OFFICE USE -- -- Z-3----- ----- ----------- --�-------------------------- APPLICATION FOR SANITATION PERMIT Permit No. -- �� ------------------------------------------- (Complete in Duplicate) Date Issued -------- 6 � � _--"__-- "________________.-__ 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 Ordi ante No. 549. JOB ADDRESS AND LWAT10N_...t. --- ........................ Owner s Name------- .1---- -�------/ --..... Phone....------•---•----------• -------- Address -`-r'r'wl_ -----------•--•-----------------------------•--....................... ................................. ------- Phone----------------------------------- Contractor's Name-------------- Installation will serve: Residence E�r Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: ----I.. Number of bedrooms ._Number of baths J_.. Lot size -- • -------------- Water Supply: Public system ❑ y y Community system ❑ Private [Depth TO Water Table Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe�ardpan ❑ UV Previous Application Made: (If yes,date--------------------) No New Construction: Yes U�-1�o ❑ FHA/VA: Yes ElNo TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.)r I d. - Material i-�'v - ------------ $epti T {r Distance from nearest well010—__-_-__Distance from foundation__ " No. of compartments ---•-Size- Liquid depth . Capacity...__3D `x'J Size-- Disposal Field: Distance from nearest well_____---------Distance from foundation---1A__-__...___Distance to nearest lot line.___°�__---- y Number of lines____________ _______r_ Length of each line____ 'Q-_-o__.-----_.Width of trench.___:__..f`--�................... Type of filter material 4!_ ------Depth of filter material___ _____________Total length__..----/�:____--. --------.-----.---- Seepage Pit: Distance to nearest well:_--------------------Distance from foundation--------------_____.Distance to nearest lot line----------------- El Number of pits.,--------------------Lining material-----------------------Size: Diameter---- ------Depth--------------------•----------•- 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)------------------------------------- ------•-----•-•--•---•-------_--------------•----------------- S ------------------•-------------------------- -------------• --------------- ------•---------•-------------•-----------•-------•------------------------------------------- ----------------------------------------------------------- -------------------------------------------------•------------------------------------------------------------••-------------------------------- 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 r ulations of the San Joaquin Local Health District. (Owner and/or Contractor) (Signed)-_ --------- ------- ------------------------ --------------(Title)----------------------------------- - -------------- (Plot plan, showing size 0 ot, I c tion of syst in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED By------ r --------------------------------------------------------- DATE__ Q Z3' REVIEWED, BY---------------------------------------•-------------------------•----------------------------------------------------- DA ----._ DATE---------------------- - `BUILD1N.G%P.ERMIT ISSUED-----------------------------------------------•-----------•------------- -- ---------•---------------•---- -- AiFera4ions•and/or recommendations:-------------- --------- -----------------------------.----••-------•-•-----•----•-•-•-----..._....._..--•---------•-----------•------------•-------- ------ ----- .f, ---•--------------"----•--••------••------ --,i ,�J! ---------------------------------------------- :., . <:. FINAL INSPECTION BY:._C......C� --------- Date i � ..----------- ------------------------------ SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,California Manteca,California Tracy,California ES 9 REVISED B-59 2M 5-62 ATLAS I