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FOR OFFICE USE: p --------------- ----------------- ----------------------- APPLICATION FOR SANITATION PERMIT Permit No. -./ .. ..t .... -------------------------------------------------------- --------------------------------------------------------- (Complete in Duplicate) Date Issued / . --------------------- ----------------------------- This Permit Expires 1 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 C�ojunty Ordin ince No. 549. % JOB ADDRESS AND OCATION-----�T/-1------ !/ --------------------------------------------- Owner's Name '-------------- Phone ..---- Address ---------------------------------•-----•--------•------------------- Contractor's Name__----- ��✓ Phone.. Installation will serve: Residence 'Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: __C--__ Number of bedrooms._ Number of baths /.... Lot size _________________________________ Water Supply: Public system ❑ Community system Private ❑ Depth To Water Table1�d' -ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe 14j-'gardpan ❑ Previous Application Made: (If yes,date---.----------------) No 0,--New Construction: Yes E&--O-No ❑ FHA/VA: Yes ®-1"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____."�-___Distanrg from f undation_-/1,9Mat r L_�_� t/ ______--_-. No. of com artments.. _.__..5iz �� Liquid dept---�t" ----------Capacity_ - .__ Disposal -eld: Distance from nears well____—____..._Distance from foundation__ __._...Distance to nearest Igt line Number of lines___________ __ ______ Length of each linef Width of trench_____. \ Type of filter materiaDepth of !{ter materia! Total length � ` ` r � Distance to nearest well_______________ ____Distance fr m fo da#ion__L .....___. ante to nearest�txline____.___. Seepage Pit: Number of pits____ __________Lining material ? Size: Diameter W'�._______.DepZe0__1 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 lot line-- --------------------------------------------------- ._.. d Remodeling and/or repairing {describe):-------~-0!!% r � ` ------------------------------------•----.-.--•-------------- ••--------------------------------••-----•----•--•-•--------------------------------•-------------------------•-•------------------------------------ -•------------------------------------------•---------•------------------------------••--•--••---------------•-----•....•---------------------------------------------------------------------------------------------- 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 and regulations of the San Joaquin Local Health District. (Signed)................ ..........L 7 ✓ ----------------------------_ - r Contractor) By: - ---------- ---- ----- (Title) - = (Plot plan, showing size of lot, location of system in re on to wells, buildings, etc., can be placed on reverse side). FORD ARTM NT USE ONLY APPLICATION ACCEPTED BY- - -- - -- DATE..... L� --•• �'� --------------- REVIEWEDBY------••---------------- ---------------- - ----------- -------------------------- -•• DATE----------------- ------------------------------------------ BUILDING •-BUILDING PERMIT ISSUED--------------- - -----•-- DAT ----- Alterations and/or recommend'ations:__ -.---- / ___ —.................................... ---•-----•-------•-------------•---•---•--- ------- --------------------------------------------------- ----------------------•----••---------.••------•--------••-•-------------- ---------• --------------------------------- -------------------------------------------------------- .................................. ----------------------------------------------------- --------------- -- ----------------- --------- ----- ------------------------------•--------•--------•--------------------------------------•----•--•--...... FINAL INSPECTION BYrr---------- Date,�� _-- _--_ -------------------------- SAN AQUIN L AL HEALTH DISTRICT 130 South American Street 300 West Oak Svr•et 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,California Manteca,California Tracy,California ES 9 REVISED 6-59 2M. 5-62 ATLAS