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FOR OFFICE USE: ----------------- ------------------------____---_-_.______..___.--_____-. APPLICATION FOR SANITATION PERMIT Permit No. ..22.......�� ------------------ ----------------- ------ ------------- (Complete in Duplicate) ----------------- ----------------- This Permit Ex ires ] Year From Date Issued 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 Ordinance No. 549. ,LI-A A-)`-, 00-7-pV-0-2-1 �.��bC�(a h�• �Lc.�Y-7,�ate• � �� ----------------------- -^ r r' � JOB ADDRESS ANA OCATION.__.0tt.5//k 1� Owner's Name__.._.{• ---- -0t,.W........-- 1''rJ x'17 -----------•- ------------------------------------------------------ Phone.FI/7.�d_l S Address._.- vX .. "''t �.CJ Contractor's .................... Phone................................... Installation will serve: ResidenceA artment HousG3 p ❑ ornmerc�al ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: ------.- Number of bedrooms __ _ Number of baths .j- Lot size ___15 - Wafer Supply: Public system ❑ Community system ❑ Private L&-Qepth To Water Table ktr 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....... .........} No .❑ New Construction: Yes ❑ No ❑ FHA/VA: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tank: Distance from nearest well_________________Distance from foundation--------------...__.Material_..________.________..____.._-_--.___... ElNo. of compartments--------------------------Size----_-------------------------.Liquid depth--------------------------Capacity------------------------ -•-----• (�N Disposal Field: Distance from nearest well------------------Distance from foundation....................Distance to nearest lot line-___.__......._.. ❑ Number of lines---------------•-------------------Length of each line---.------------.-•----------.Width of trench...------•--..--------..._--- Type o filter material.---•--------------------Depth of filter material-----------------------Total length---.....----------------.--------------- Seepage P' Distance to nearest wel1lrfim ---- -----Distance from �foundation _�.'.____:_.Distance to nearest lot line'C..�.__.__.._ Number of pits.__.j______________Lining material_/).,- ------ Diameter__ 3---------------- 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 ______ ______Remodelin and/or repairing describe : ---•- --------••-----------------•-------------------------------------------------------------------------------------•------•----------------•----------•------------------•----------------•--------....--•--------------------------- 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 rul s and regulations of the San Joaquin Local Health District. (Signed)_ ____________________(Owner and/or Contractor) By:------------------------------------------------------------------------------------------------------------------------------------rifle (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 \ k APPLICATION-ACCEPTED BY_ '--------------------------------- - - -------------- ---- DATE__�f=---�y��-----------•------------------- REVIEWED BY-------------------------------------------------------------------- •-------------------•-------- DATE-------------------------- BUILDING PERMIT ISSUED_...-------------------------------------------•--------------------•--• -------------•--------- DATE_------_---------------- -- A erations and/or recommendations------------------------------------------------ -• -------------- -------------------------------•---------------------•----------..._------.----.--...._ ----..---•---------------------------•------••-----------•----- ----- -- -- ---••-----•------------•----- ----•-•- ----- � ------- ---------------- - -------------........ ...... 4--t-w/ FIS INSPECTION BY:_ --------------- Date . ` SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Srreel 124 Sycamore Street 205 Wort 91h Street Stockton,California p Lodi,Californias Manteca,California Tracy,Collfomia ES 9 REVISED 8-59 2M 5-62 ATLAS � 1