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FOR OFFICE USE: --------------------------------------------------------- APPLICATION FOR ' ��.19 ________________________________________________________ SANITATION PERMIT Permit No. _._...._.._. . ._..... --------------------------------------------------- (Complete in' Duplicate) ° l7 _....-._..-----..._.-__-------.......... ............. This Permit Exyires 1 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. S49. JOB ADDRESS AN OCATION....`�' ..- - "�` '-----� _�1--1+c1------ --- -. _ Owner's Nam -- l �.�if.6: Phone ...._...n........ Address•••-- ......./...... '----•-•• t u• -... Contractor's Name...--- • _.. .. .... '....... ......... . .. -------•-------- Phone Installation will serve: Residence ❑ Apartmen.,House ❑ Commercial Trailer Court 01 Motel ❑ Other ❑ ,I Number of living units: -------- Number of bedrooms -------- Number of baths -------- Lot size ....................................:................................. r Water Supply: Public system ❑ Community system [I Private it Depth to Water Table ..._ `ft. u k i r Character of soil to a"depthfof 3 fee+: Sand Gravel ❑ Sandy Loam F] Clay Loam ElClay ❑` Adobe❑ HardpanO Previous Application Made: (If yes,date--------------- No,9 New Construction: Yes No ❑ FHA/VA: Yeas ❑ Nci W fYK OF INSTALLATION AND SPfCIFICATIONS: (No septic tank Ior cesspool pbrmi#ed if public sewer is available within 200 feet.) SeV ankt Distance from nearest well...,§Q.......Distance from foundation----.�0.........Material......-- i? �.............. ( No. of compartments---------.--------------- e ..�+'.�1..._._X.. .__.Liquid depth........ `- ...Capacity...hSd.R..... Dispos If Field: Distance from nearest well..... --------Distance from foundation......L.d_..f....Distance to nearest lot line___.......... ( 3 Number of lines-------------L--------------------Length of each l ine___._.j.fl_U._. ,_.....Width of trench... --. --...._._..._..•--- � l i Type of filter Depth of filter material------- length.......... ........ Seeps _ it: Distance to nearest well-- --h-Q-/..-.Distance from foundation-_-J.D.........Dista ce to nearest lot line..-_t�-------- Number of pits--------2--------Lining material..,A."-. -..Size: Dia meter._...1��.��...Depth------ 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._._...._.._....___.______....._---------- - k ❑ + Distance to nearest lot line------------------------------------------- -•--• -------------------------------•-------•--•-•- . Remodeling and/or repairing Idescrib-p):-----------------------•----•--------------------------------------------------------------------.....----------------•-•----•---------••- t _----....---•-•----------------------••-•-----••-•- --- � tmm-m , .....................................•-------------..............---------------------------------------------- .q ► 1 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances,: tate laws, arA rules and regulations Orf the San Joaquin Local Health District. ' nor end or Contractor) (Signed)BY� ••. 3 -- ----------------------------------------•---.(Title)----•---------------------•• -----•------------- ------------- (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse-side). 1 y FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY-- = ------- ------- -----•----•-••------•--••-------- DATE_47 y REVIEWED BY-----------------•------ -- DAT --------------- - -------- •--_---••-------•--------------- BUILDINt, PERMIT ISSUED-----•------------- ----------------...-------------—.................................--•-- DATE.------•-------------_•--- ....--------------------- Alterations ein`d/or recommendations:.-------•-- --------------- ------------•--•-•-------- ----------------------------------------------------___--------- i 1 ` C- - Y ................................................................................................................................................................................................ ......................... FINAL INSPECTION BY:.,/ .. ' --- Date --------------------------------------------------- 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,BEV111E0 8.99 2M 9-61 ATLAS