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FOR OFFICE USE: T x' __ '_�—_------- APPLICATION FOR SANITATION PERMIT Permit No. -------------------------------------------------------- (Complete in Duplicate) HCl -------------------------------------------------- --- This Permit Expires I Year From Date Issued Date Issued ................7� 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------ g0- __ _'.._I�• ----------------------------------- Owner's Name Phone.. Address - ----- --- ----- Contractor's Name ...._ ._.....I_f.�_xn, Y' .............................. ....... Phone 4 �--z Installation will serve: Residence E?/Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ r Number of living units: ----t_ Number of bedrooms ___I___ Number of baths ---I... Lot size ___._4_Lf /_____________________________ Water Supply: Public system Community system ❑ Private ❑ Depth To Water Table 46- ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sa y Loam E] Clay Clay Loam Clay ❑ Adobe Hardpan El Previous Application Made: (if yes,date---------------__--) No (kNew Construction: Yes [ No ❑ FHA/VA. Yes ❑ No DR-1-C TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 204 feet.) Sep " T "� Distance from nearest well_________________Distance from foundation------..............Material...__________________________•--_--._-_--:_'._..� {4r No. of compartments--------------------------Size-----------------------•-----•--Liquid depth---------- --- -----------Capacity------------�/------ Disposa 1=field: Distance from nearest well______.__Distance from foundation-� ______-___.Distance to nearest lot line____.__._.... Number of lines.............I-----------------.__-Length of each line.__:�"I."."____...............Width of trench_._ ..................... Type of filter ma#erial._.IK!4-_ Depth of filter material___/ _____________Total Ienc}th____._..__ a....................____ 1 � Seepage Pit: Distance to nearest well__/4Q___________Distance�m foundation---IR...........Distance to nearest lot line... ........... Number of pits._________----------Lining material______�__.q_G/-(---Size: Diameter____.............Depth------ --- ----------- 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-----------------------�•pp----�----------------:------�-------------•------�---_.---------------•-----------------•---•�f-••---.._..._-- Remodeling an /or r airing)descri .-• ---_--_•- 0A11 i-----7---------------------------- �..::.::.::::: % -__-: - � � --__----- I _- hereby certify that I have prepared this application and that the work will be done in accordance with San Joa nty ordinances, State laws, and rules and regulations of the San Joaquin Local Health District. q (Signed)--------------------------------------- ---••-----•----•------ ------ --- - -- - (Owner and/or Contractor) By:-------------------------------------------- ------- ---------- ---, ---------------------------------------------(Title)---------------------- (Plot plan, showing size of lot, locati sys em in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY t APPLICATION ACCEPTED BY-- . -----6&Z-- -- ---- - ----•-------------------------------------- DATE-•---7 ..� -•-•-••----------------- REVIEWEDBY--------•------------------- - ------------------------ DATE----- -•---•-------------------------------------------- BUILDINGPERMIT ISSUED----------------------------------------------------------------------------- . ...... DATE------------------------------------------------------------- Alterations and/or recommendations:---'jrn_..—--'-.��.. ... ��= ----------------------- ---------------------------•------------•-•-•----- -----------------------------------------------------------------------------------------------------------------------------------......... .. ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ FINAL INSPECTION BY:..- ----------• -------- Date---- ..... -•------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 124 Sycamore Street 205 West 9th Strut Stockton,California Lodi,California Manteca,California Tracy,California E5 9 REVISED B-59 2M 5-62 ATLAS