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FOR OFFICE USE: �� ' --------------.t ---------------------------------- / ----- - APPLICATION FOR SANITATION .-cRMIT Permit No. __1 �.�i� (Complete in Duplicate) Z This Permit Expires 1 Year From Date Issued Date Issued ...... .......U Application is hereby made to the San Joaquin Local Health District for permit to construct and install the work herein described. This app is I is read in com • ce i Cou dinance No. 549. JOB ADDRESS AA LOC I N. :-- - — !✓ —,.o.. Owner's Name .- Ir !/ -------------- Phoe----••----... +c-� ' --------------- ---- ---•--.........---- - ---- Address-----...---••--------- ----- a �--------------------- --• Contractor's Name._._.. �'� --------- �� ---------------------------- Phone........................ Installation will serve: Residence ❑ Apartm nt House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Otherpi' �/� Number of living units: Number of bedrooms Number of baths Lot size _ ----. ........ Water Supply: Public system ❑ Community system ❑ Private ❑ Depth to Water Table ________ 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 g?"No ❑ FHA/VA: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) SF, t' Tank: Distance from nearest well---..., _ ..Distance from foundation-------,�.0_..___.Material...._ � -��- -------------- No. of compartments_____-.�l--------------Size. ffl.OX__(....__.__.Liquid depth......!.�-------------Capacity_/ ..... Disposal Field: Distance from nearest Distance from foundation..l�__ -------Distance to nearest lot line-J.1`._._.. ' Number of lines-----------•___-__._ .___ Length of each line-___-__'' -- 9 7--��---• ............•---•----...Width of trench-----�=-------------------------- Type of filter material-_,1of filter material_______ EI'_`s ------Total length____._/. d..�..................... SeePit: Distance to nearest well----j vp__..____Distance from foundation____//A ... .. ..... to nearest lot line__-S_�.___.- 7 Number of pits----------- ----_-----Lining material__hl_! ------Size: Diameter_...S., ---------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 loft line---------------------------------- -----------------------------•---------------•-------•---..--•--------.--_....---------------------------- Remodeling and/or repairing (describe)________________________ _ __ -------------------------------------•--------•--------------- ----------------------- ....r.=---- -e --------------------------------------------------------------------------•------------ ------------------------------••-------••-----••------••---------------•---._....------------•----------------------------------- 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 r les and regulations of the San Joaquin Local Health District. { a (Owner and/or Contractor (Signed) r -- - --- -- -------- --•---.---. --------.... / l - --------------------- - �Y� ----------------------------- -- ---------- {T'itle) (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 _ -- z ------------------------------------------------------- DATE----J'_l_.._�G y REVIEWEDBY-------- ---------------------------------------------------------------- DATE------------------ -------------•- •---••----------•------- BUILDING PERMIT ISSUED-------------------------------------------------------------- ------ DA•TE--.------------•------. ----------- -------------------- Alterations and/or recommendations:------------------ -------------------------------..............................................................................................-------------- 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 EE 9 REVISED B•69 VA 6-61 ATLAS