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FOR 01�6USY' _ # L ------------_/.._._.__._:.__..__._..___..1F'- APPLICATION FOR SANITATION PERMIT Permit No. C .. . ..�-" ----- -------------------- - ------------------------ ---- (Complete in Duplicate) // Date Issued -----------_______------------_-----_-------------------- This Permit Ex fires 1 Year From Date Issued ..-•-.�-�-_-.fit v Application is hereby made to the San Joaquin Local Health District for a permit to cons ruct and install the work herein described. This application is made in compliance with County Ordinance No. 541. JOB ADDRESS �LOC - 7_ ._. ! - ---- ---- .. ....-• --•-••---- ............... ..........••- Owner's Name... ...... .. Phone...............•----------- Address � - •--�W�- ---•------------------ .............. ------ Contractor's Name _ .t �� -. _�..✓;- � 4 ------------------------------- Pho .�� Installation will serve: Residence E]-partment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ ' Number of living units: ,_/--- Number of bedroo -, Number of baths /-- Lot size ____. J.... _f ..�.._. Water Supply: Public syste ommunity system C] Private ElDepth to Water Table _ eft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobed Hardpan ❑ Previous Application Made: (If yes,date--------------------) No ❑ New Construction: Yes ❑ NIDA— FHA/VA: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: SbNo septic tank or cesspool permitted if public sewer is available within 200 feet.] T Distance from nearest well_________________Distance from foundation...................Material................................................. No. of compartments--------------------------Size--------------------------------Liquid depth.......... ---------------Capacity.......... osal eld• Distance from nearest well._'.Z_rXt--t}istance from foundation____ Distance to nearest lot line f � �( Number of lines----.---r._ __ Length of each lin� z9__`__p ,___.Width of trench.4 �"_____________ ` ' ` Type of filter materia{, , r _-__-_ Depth of filter material_____I!J__ __ .Total length____�'___e-_____________________/ Se �e Pit: Dis#ante to nearest well_M____ ___________Distance m fqundation__...�4_.--.D,10a33c�e to nearest lot -in�. C.�.... Number of pits----/______________Lining material... ��c-_.�. _.'-:Size: Diameter__ c�_._.__•.Depth ................... Cesspool: Distance from nearest well-----------------Distance from oundation---___-__:._-.-__.Lining material------------------------------------- ❑ Size: Diameter Depth Liquid Capacity---------------------------gals. Privy: Distance from nearest well-------------------------t---------- ------Distance from nearest building___________._......______.._.._._._...: ❑ Distance to nearest lot line------------------------------------------ ------•---•----•-••-----------•----•----- ----•-------•---------------------------•- Remodeling and/or repairing (describe):----------------- ---------------------------------=------------------•----------------•••---•-•--------•-----•-•---------------------------•-------- '�-, -------•------------------------------------------------------ -= --------------------- - ---. ------- . •--- •• - ---------- I eby c hat I Have pre�r is ap is ion and that th work will be done in accordance with San Joaquin County ordi nce , t ws,/�nd rule -e regulations of the San Jo ui Local Health District. - r (Signed) .....�4g/V—, r.! ` . ..... ...... ....... . ...... ....... 7. Contractor) ---------------------- -------------------- ---------------•--• Title------------•------------...................................... y ( } (Plot plan, showing size of lot, location of system in relation t ells, buildings, c., can be placed on reverse side]. FOR DE RT NT USE ONLY APPLICATION ACCEPTED BY---------- ---- ---- DATE...... r_- --•------------_----- . -- ------- -- ---------- -------------------- REVIEWEDBY---------------------------------- ------•-------------------•------------------•--------------------- ... ...... DATE------------------------------------------------------------- _ BUILDING PERMIT ISSUED--------------------------------------------•-••--------•-1-------------------------------•----------- DATE-•------•---------------- -----------------Alterations and/or recommendations: -----o - - •-........... ; -•---------------------------------•-------------------------•---------------------------• ------ --- ------------•-----------------------------------•---------------•------------------.......--------------------_---•---- ------------------------------------------------ ------------------------------------------------------•---•---- ------ --- ------------- -----------------------------------------------------------------------------------------------------•-•---------------------- --------------------••----•----------------- -_..._--._.... •-----------------------------------•-----•-------------•--•--------•-•-•---•--•---- /�, ------------------------------- *...... .... --/ FINAL INSPECTION BY------- ------- --------._------ ----------. Date---- -- _-__f._-_1-- Z` SANJOAQUIN LOCAL HEALTH DISTRICT 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 B-59 2M 5-61 ATLAS