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FO OFFI� USS r--------- ------- f f l/ ------ ._.�, APPLICATION FOR SANITATION PERMIT Permit No. --------------------------------------------------------- // ------------------------------------------------------- (Complete in Duplicate) Date Issued ... Sy -------------------_---------_--------------- 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 County Ordinance No. 549. ."---••--- ------•------•-•-----•- JOB ADDRESS AND LOCATION- Q- --------------3 ------ . '--.... ....----•---- ± - •-•----- Owner's Name------------ ` ................C."t__.._r�_ '`� _ Phone... �� Address-_ -Z 1..5.-5_ _ ---------------_---------------------------•-•-----...__------------------------------------------------------------ :1 ------•----------•------------•------------ •--------- Contractor's Name-------•--•----•� -• - Phone_..._.. Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑/ O(ther 0 Number of living units:,:__�._.. Number of bedrooms ---/--- Number of baths ----/_ Lot size ____. .-..1-=-- Water Supply: Public systanil Community system ❑ Private ❑ Depth to Water Table -------- ft. Character of soil to a depth of 3 feet:-.-Sand-❑ Gravel-0- -Sandy Loam ❑ Clay Loam-[3---Glay-E]---Adobe Hardpan ❑ PP a es,date_______________ Previous Application Made: [If __._ I No New Construction: Yes ❑ No E] FHA/VA_Yes ❑ No TYPE OF INSTALLATION AND SPECIFICATIONS: ( p spool permitted if public sewer is-available-within 200 feet.) No septic tank or ces � Septic T nk Distance 'from nearest well-50 M)4 Distance from fornda f on�__!f[ ht--.Material.7_____.___1'.___.......��.............. No.. of compartments-______ . --- Sizq-- Liquid de th_____ _..""- ___._-__Capacity.... •��d Disposal Field: Distance from nearest well_________________Distance from foundation....................Distance to nearest lot line........... egPi, Number of lines---------------------------------•_Length of 'each line--------.---------------------Width of;trench"_"-_-----------_---------•------ Type of filter material_________________________Depth of filter material-_______-..---______-Total length--______.._...___._......______......._.__ Seepat: Distance fo nearest well----------------------Distance from-foundation....................Distance to nearest lot line---.............. ❑ Number of pits-"------- ---------"-Lining material---------.-------------Size: Diameter._....-----------""-!-:Depth--------------------------------- e 1 � " i. � Cesspool: Distance from nearest well______________"-.Distance from foundation.-------------------Lining material....____._._...-_-____..........__-•_ ---Liquid Capacity --------------gals. ❑ Size.: Diameter _= -------------_'" __Depth-----`---------------------------- Privy: _-•-- ----- P tY Privy: Distance"from nearestwell_`_______--------______________-;-------------distance from nearest building------------------------------------------ ❑ Distance to nearest lot line---------------•.,-------------- ---------••-•._....--------=-----...:...-------•--------•------ • 9 p _ ; describe ----•--- ----•------ ._ 9 �= ...-------•------------=- - ----------- --------------------------- i. ... = - •... Remodeling and/or re airm ;- ._.... -----•---------------------•---•-••----.... ------------------- =-------'----•--•--••-----------------• -----------•-•-•... - --•---------------•-•----- -_....-- ------•--------------..----------------------------- I herebycertify prepared this application and at the work will be done in accordance with San Joaquin County Y ordinances, State laand gulations of the San aquin Local Health District. (Signed) ................(Owner and/or Contractor) _ �' ' -- --••------.(rifle).......................----•• •---••-------- -------- ------- By:.------•---••--•---••-•-•. ............•--------•----------•- ----------- --------------- .... - (Plot plan. showing size of lot, location of system in relation to wells, buil ings, etc., can be placed on reverse side). t FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED I}�1�� DATE ----------------------------- ----------------- REVIEWEDBY--------------------- ------- ------- ------------------------------------------------' ------------ DATE------------------------------------------------------------ BUILDING PERMIT ISSUED...:---------------------------------- ••-------------._..---------------- ---------- DATE. Alterations and/or recommendations:---------------------- -------------------- "..--•-----•-----••-...-----....-----•----•-.._...------•-•--------••---•--•-•--------------••�•--•----- n --------•-----------•----------------•-••-------•---------------•-------------......------------ } l --------- --------•------------------------ ...--------.._._. i ' 6 Axe— J Date_.. ��..__.7.'..."----------------------••--- FINAL INSPECTION BY: -rl------ ---- --._.- .�, SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Ock Street 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,California Manteca,California Tracy,California E6 9 REVISED 8-59 2M 5.61 ATLAS