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t FOR OFFICE US� $; . .T 3. " - ------------ ------------- o / Permit No. - -..� D� APPLICATION FOR SANITATION PERMIT ,1----•--- - _---/� - ----- , ��- ---------- (Complete in Duplicate) / � Date Issued - ------------------- ----------------------------------- This Permit Expires 1 Year From Date Issued t 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 Ordin rice No. 549. JOB ADDRESS AND CATION.-- / -- � -------- Owner's Name---- - - - -- - -• -- ---- --•-•--••-•----------------------•----------------------------------------------- ---------- Phone...--•------------------------------ Address.—IJ�...----- --- ----------------------------------------•--------------------------------------•-••---------------------------•---•------------------------•------- Contractor's Name.. ------------------------------ ---•------------------------------------------------------------ Phone---------------------------------- Installation will serve: Residence E 4"'Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: .___ Number of bedrooms ;?_- Number of baths C.___ Lot size _________________________________ i 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 23--Iqardpan ❑ Previous Application Made: (If yes,date-------------------_7 No [D""'New Construction: Yes 9?'No ❑ FHA/VA: Yes Py'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 roan foundation---le--------Mater�pl_ .......... I No. of compartments------a ----------Si __ _ '...Liquid clep,h_____j��--_.__ Capacity___. ___.__ ' Disposal Field: Distance from nearest well--- __ Distance from foundation___ ___ ..• nearest ® - ,f�_-...__Distance to lo+ line_.____._._.. ®� Number of lines..... _-__.____ Length of each line_._s�V�._ Width of trench._A-_f..�___________________ Type of filter material. .Depth of filter material___. ________Total length___/, _______________ Seepage Pit: Distance to nearest well----------___---------Distance fcom foI__---Size: Diameter nclation--- ---------Dista ce to nearest lot Number of pits______/-__________Lining mate rial_ __. .0.......Depth_. a '�1 (A Cesspool: Distance from nearest well-----------------Distance from foundation--------------------- material-_.___...--__________........_...... ❑ Size: Diameter------------------ ----- -------------Depth---------;----------•------------------------------Liquid Capacity_. gals. I Privy: Distance from nearest well. ----------------------------------_-------------Distance from nearest buildiri 4*. 9t ❑ Distance to nearest lot line---------------------------------------------------------------- _ ------------------ ...-•--••--------------------------- Remodeling and/or repairing (describe :-------- -----/'G - -------•---- •----- ---- , -------- ---------------------------------------------•--------•---------------•---------------- ----- tr , 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 rules a,9d regulations of the San Joaquin Local Health District. (Signed).......................... .7� Gtr/l --------- ( /or Contractor) �---- Title-- € (Plot plan, showing size of lot, location of system in rel to wells, buildings, etc., can be placed on reverse side). ` R DEPART ENT USE ONLY i, APPLICATION ACCEPTED BY_ _-- -_ --- ---- -- ------------ DATE..... _. -- ---------------- REVIEWEDBY-------------------------------------------------------------------- ------------------ -----------------......... DATE------------------------- --------------------------------- BUILDING PERMIT ISSUED--------------------- ........ ' y ,erf ---- _ DATE-------•----------------------------------------------------- jAlterations and/or recommendations:-•-- --------•----••-•-----•- ----------------------------------------------- -----------------------------•------- -------------••--- •---- - ---- ------------------- --••------------------------------------------ - FINAL INSPECTION BY: - --- ----- Date-----� -� ---��- ------------------- f, SAN JOA UIN LO AL HEALTH DISTRICT 130 South American Street 300 West Oak Street 1424 Sycamore Street 205 West 9Th Street Stockton,California Lodi,California Manteca,California Tracy,California E5 9 REVISE[) $-59 2M 5-62 ATLAS