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,f - FOR OFFI E -- ------------ -- --------------- APPLICATION FOR SANITATION PERMIT Permit No. ...��_-�. -----------/--------- --------- -------------- r --------------------------------------------------------- (Complete in Duplicate) . //G /0/-3 ________-______.__ This Permit Expires 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 descrbed. This application is made in compliance with County Ordinance No. 549. JOB ADDRESS AND CATION ____ ----------------------------------------.----- •--•-••-•-----...------•-------------•----.----•.---- Owner's Name--------- ---- ^.. -- --- ------ --.. ...... Phone.................................... Address. 0 --- ----•---------------------------- Contractor's Name................. . — � - -.""------------------------- Installation -----�-- -- = Phone..... Installation will serve: Residence �artment'House ❑ Co rilrr ercial ❑ Trailer. Court ❑ Motel ❑ Other ❑ Number of living units: __`__ Number of-bedrooms Number of baths ._I--- Lot size___ _ __ _ �_____________________________ Water Supply: Public system ❑ Community System [i?'Frivate ❑ Depth ro Water Table ft. t Character of soil to a depth of 3 feat:-Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe ardpan ❑ Previous Application Wade: (If yles,date--------------------) No RR-'New Construction.: Yes k-No'❑ FHA/VA.. Yes R2--'No ❑ TYPE OF INSTALLATION AND 'SPECIFICATIONS: (No septic tank or cesspool,permitted if public sewer is available within•200 feet.) ? Septic Tank. Distance froml nearest well___' �__-_Distance from foundation---A9.......Material..� ____ _______________ (J�}� No. of compartments_____ i-_______________Size.i } 0""_Liquid dep��h___�71;1!._________Capacity. --fl�--•_ Disposal Field: Distance froJ earest well__--`__._Distance tram foundation_./�_._......Disttance to nearest l line.A;:F7 ..... Number of'•li es_ _________ ____-. _-z__ -Len th of a Lc ine..� r ---- �r � .�-�.• - g - -. _LL w1f`�--.-..., Width of trench..-------- ------------------ Type of filtefh+materlal.4Depth of filter material---/P ------Total length....I _.�__________________ i ___-_Distance fr m foundation—__ �.- D tante to nearest I t line__ ....�1._____ Seepage Pit: Distance to�nearesfi well-------- fC6.._._-. _ Number of pits---..A------------Lining materiaL/e��.Size: Diameter_..F�----Depth- __�................ Cesspool: Distance from{nearest well............. ...Distance from foundation--------------------Lining material--------------.---------------------- ❑ Size: Diamet --------------------------------------Depth----------------------------------------------------Liquid Capacity----------------------------gals. At Privy: Distance --------------------------Distance from nearest building----------------------------._-.__.______- ❑ Distance to near`e�t-`lot-liffe -- ------ -- - 4 � f n •_______________________ Remodeling and/or repairing (describe):__---- -------•-•-•---•-^ ------_--•--------------------•-------------•-------...------'-•---....-....--------------------•--••--------_---------------------.....-----------•----------------------- ` I hereby certify that 1 here prepared this application and that the work will be done in accordance with San Joaquin County �} ordinances, State lawUandr,11 andregulations o the San Joaquin Local Health District. •-•--------`-1Q WA =mor Contractor)(Signed) J .._(Title}By--------------------------------- ------.......-------------- ------------------- ,� ------ ---------------------- I (Plot plan, showing size of lot! location of system in relat' to wells, buildings, etc., can be placed of reverse side). t t 4_ --'-- ---FOR-D' A-RTWEM-USE`O"11LY APPLICATION ACCEPTED BY D.A.TE___� __._. ___Gx.....__ 1 - ---- --- - ------------------ice-..:_„-�._� - -- ------------ REVIEWEDBY-------------------------------------------------- -------- ------------------- ------------------------------- DATE BUILDING PERMIT ISSUED---•------------------ -- ---- __ ...__•-___-- TE Alterations and/or recommendations:-- ----- - ------ - -- - ----------•--•---•-•---•--•--••--••-----•------------ FINAL INSPECTION :.- '-- --•- -_-- Date_ ----- SAN AQUIN OCAL HEALTH DISTRIC 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 8.59 2M 5-62 ATLAS