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FOR OFFICE USE:-------------------------------------------------------- - _ -_..-..__..°...............................__.____-_-. APPLICATION FOR SANITATION PERMIT Permit No. --------------------------------------- ----------------- (Complete in Duplicate) (� Date Issued ------------------- This Permit Expires i 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 Ordinance No. 544. JOBADDRESS AND LO TION...____ U: __ _ ------------------------------------------------------------------ ------------•-•-------------------------------••-------- Owner's Name------------- .,..f- -. _-...��.. ..�. ._.. ,. Ohone----------------•-•-- --- -- - - ----------�P- -- --- ------------ ------------------------------- Address �� -----••------... -------------------•----- --------------- ;_ - Contractor's Name -----------------•------------------------•-------- Phone i r Installation will serve: Residence qi_�partment-House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of livingunits: ._.- NumbJ o� bedrooms ..3__ Number of baths _ .. / __ - �--- Lot size _ s�,�-- -__'-�_-•----.....--••-•-•---•----------- Water Supply: Public system ❑ Commt;nit system Private ❑ Depth To Water Table AA tt. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe Ea-lTardgan ❑ Previous Application Made: (If yes,date-__.___-{_.._----_ -) No I4-'-New Construction: Yes [E-'10 ❑ FHA/VA: Yes 99--No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic Tank or cesspool permitted i public sewer is available within 200 feet.) Septic Tank: Distance from neares�twell____==-___Dis#an�er�om found�ation___,� �_ �i ,��• No. of com artmentsr-F 4_ t�4VO_.___Liquid depth____ Ca aci Lfr?' P ._.-�..-----•---------Size-- ----------- � .............- Capacity... tY•--��-�--•--- Disposal Field: Distance from nearest,,well________________ Distance from foundation--- -----------Distance to nearest lot line................... g ��' o �! Width of trench._�!..--...---•-------------- [� Number of lines______�,r._-._�.____ ___ Length of each line___ __ - �. � f Type of filter material, Depth of filter material.._'_--._-_..--Total length____�$„�/ _______________________ Seepage Pit: Distance to nearest well,_-J--- —`-- Distance.4 om-fou dation,__-/�:.__.___.Dist"I cb'to'nearelst lot line-6 Number of pits____r_______ _Lining material_ ..._ _..Size: Diameter_,_._1......Depth__..;:Z�---________________ V Cesspool: Distance from nearest well-_______________Distance from foundation---.-----------.---.Lining material..-___.____-___.__-.-__________----El .. r t Size: Diameter------------:_- p ----------------------------------------------------Liquid Capacity---------------------------gals. Privy: Distance from nearest well_+----_-------------------------------------------Distance from nearest building--------------------------.--------------- ❑ Distance to nearest lot -_ ------------------ Remodeling and/or repairing (describe):--------------- < j - • -----------------•---------- ------------------------- t ------------•-------------------------------------------------------------------------------------------; -••-------------------------------- --------------------------•---..;..-----------•-------------••- --------------------------------------- ----•---------- _.._- _ _= i---•-•--------------------•-•--------------------------•---------------------•,---•--•-------•- --------------- -----------------------------•----- ---------•----•------•---------------------------------------------------••--------------•--•-•-•-----•---------..__....-•--•---------•-------•--t-••-----------------•---------------- I hereby certify that I have prepared this application and that the work will be done in accdrdance with San Joaquin County ordinances, State laws, and rules and regulations of the San Joaquin Local Health District. f (Signed). � --�atiionto ------ ----------------------------------------- or Contractor) ! By:-------••-------------------------------------- ! -------------- (Plot plan, showing size of lot, location of system in wells, buildings, etc., can be placed on reverse side). FOR DEPAR , ENT USE ONLY APPLICATION ACCEPTED BY DATE�/REVIEWED BY ._.. DATE BUILDING PERMIT ISSUED-------------------- - ---------- • DATE TE---------------------------------------------------- Alterations and/or recommendations:__-- .--_�!r0 ___... - _ __________--------_-------------------------------_---------------------------------------------------------------------------------.------.---------------------------------------.------------------------------------------ ____________________________ FINAL INSPECTION BY/. -- ------ -- ---- --- ----- ---- Date-_Z---- --- --•-�`-- s SAN JOAQ LOCAL EALTH DISTRICT a 130 South American Street 300 West Oak Street 124 Sycamore Street 205 west 9th Street Stockton,California Lodi,California Manteca,California Tracy,California E9 9 REVISED B-59 2M 5-62 ATLAS