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FOR OFFICE QSE: 3 = � � r -P - _---_---- ------------------------- APPLICATION FOR SANITATION PERMIT Permit No. ../S-_ ------ (Complete in Duplicate) 3 Date Issued ---------------------------------------------------------- This Permit Expires 1 Year From Date Issued --.-•.-.-.-.i�./ 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 LOCA ON:---------�T / ` -------- '------------•• ...............•---•-----•---- --------------------------- or 4_. Owner's NameI. .!._ ------------------------------------- Address - Phone. - .aS 5� L..Jr_ ------ ------�-=^ -��..........-..........................----------------�=...------------------------------------ Ad d ress-_______--. .. ...... Contractor's Name..__ '----�C'.c-... �--------------------------•----------------•----------------------- Phone.. Installation will serve: Residence ❑ Apartment House [] Commercial E] Trailer Court ❑ Motel ❑ Other E)Number of living units: _--- Number of-bedrooms I---- Number of baths -------- Lot size ..................................................I......... Water Supply: Public system ❑ Community system ❑ Private ❑ Depth to Wafter Table ........ ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam El Clay Loam [3 Clay E] Adobe C] Hardpan ❑ { F Previous Application Made: (If yes,date-------r------� I No ❑ New Construction: Yes ❑ No ❑ FHA/VA: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS-. I (No septic tank'or cesspool permitted if public sewer is available within 200 feet.) Distance from nearest well_`__T-!: Distance from foundation ---_-_.-.Material_. .?......................... ....... Septic Tank: No. of compartments----- -_ ---__ Size.. ._-- 1C-- _ Li uid de th_-4-_-�- ----Ca aci sem '._: r� � q R P tY Disposal Field: Distance from nearest well.,----Distance from foundation--_-L.. �.....Distance to nearest lot line----..-t.`1...._. "'Number of lines_.____`_._- . '- -------_-Len Length of each line-_--_---q-Q_ .--_---:_:W.idth,ofarench----_--�4..'-------------- * ,, r` - 9 i� f Type of-filter material._.R,La _------Depth of filter material.....�_`7__---_----_Total length_........ 1 _____________________ Seepage Pit: .Distance to nearest well---�----Distance from foundation-i/l)_--_.._._.Distance to nearest lot line_--9--__----- Number of pits------I-------------Lining material__k7V5 l�.----.Size: Diameter-...�3_____.___-.Depth_.--2=�---•.--.-..-----.--- Cesspool: Distance from nearest.weli,-_---_:----,=Distance from foundation -Ui ingma erial------------------------------------- ❑ Size: Diameter------ ------------------------------Depth----------------------------------------------------Liquid Capacity----------------------------gals. Privy: Distance from nearest well------------------------------------------------- from nearest builcli�g.......................................... ❑ Distance to nearest lot line-----------------------------------------------------------------------------•----- ------_--------------------------------------------- Remodeling and/or repairing (describe):-----------------------------------------------------------------------------------------------------------•---•----•----------------------------------- t I ! I ! f I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State law and rules anA r gulations of the San Joaquin Local Health District. (Signed) i ----------- --------r.-.-.-a_..----•...... ------•-------------•----... -----•--- ------------------------------.(Owner and/or Contractor) By:..............--................................. ...............................---------............------..--------------------(Title)----- - (Piot plan, showing size of lot, location of system in relation to wells,•buildings;etc.;cah'be'placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY---- --------------------------------------- DATE--- -&----4------�,23----------------------- REVIEWEDBY----------------------------------------— -------------------- ------------------------------ -•--------------------.. DATE..--------------------------------------------------------- BUILDING PERMIT ISSUED------------ --------------------------------------------------------- DATE------------------------------------------------------------- Alierations and/or recom en ations------------- ---------------- --- ------ ---------- -------- -----•------•------------- i --------------------------------------------------------------•------------- ----------------------------- -------------------------------------------------------------------....------------------------ ................. ------------------------------------------------------------------------------- FINAL INSPECTION BY- ----- -- ------ ------ Date a SAN J AQUIN LO L HEALTH DISTRICT 130 South Amerlcon Street 300 West Oak Street s 144 Sycamore Street 205 West 9th Street Stockton,California Led],California x Montocdi-Callfornia Tracy,California ES 9 REVISED S-S9 2M 5-61 ATLAS f