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FOR OFFICE USV. APPLICATION FOR SANITATION PERMIT Permit No. ------------- __.1. ... . -------------- ---------------------------------------- (Complete in Duplicate) Date Issued ... --..__ _ ___- --.--.---.____..-- This Permit Expires 1 Year From Date Issued ...... .... ...1.. 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 dompliance with County Ordinance No. 549. 13 ®�Z/ JOB ADDRESS AND LOC ION•_ -li2z•��---_� a--------------------------------------------- ---- -------�°----. .s�?1 �i----------. �-° Owner's Name----� ...............-----••-------•-•--•-••----------------------------•--------•----------- ---------------------------------------• Phone------------------------------------ Address................ --------------•-------------------•Address.-----------•--- k ' = --.... ------•----- -------------------------------------------------•----------------------- ... ----------------------------•-----•--..- Contractor's Name.-----.-� � --.--..---- ...................... Contractor's 'S 1 Installation will serve: Residence ❑ Apartment House ❑ Commercial Ej' Trailer Court ❑ Motel ❑ Other ❑ Number of living units: ._?--- Number of bedrooms -------- Number of baths 3_ Lot size 0 --------------------.............. Water Supply: Public system ❑ Community system ❑ Private Q Depth To Water Table IP--- ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam Clay Loam ❑ Cay ❑ Adobe ❑ Hardpan ❑ Previous Application Made: (If yes,date--------------------) No Er__JN4ew Construction: Yes ❑ No �HA/VA: Yes ❑ No ©� TYPE OF INSTALLATION AND SPECIFICATIONS: r•�t (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tank: Distance from nearest well_ _-----...Distance from foundation__!D_-_-.._.___ �! Material-- ' _-_-------1?r-� - -- . -No. of compartments depth__. 4 _____-_.___--Capacity_1� �c Disposal Field: Distance from nearest wellA6_---.----.-Distance from foundation..l_D--'-.......--.Distance to nearest lot line................. Number of lines---...-.'�---------------------Length of each line--...$ -- ._-.---------.Width of trench--- Y----_-----------.------- Type of filter material.`�ie-e_A--------Depth of filter material--1-K._"___-------.Total length-----�Eo_�------------------------- Seepage Pit: Distance to nearest well----------------------Distance from foundation--......------------Distance to nearest lot line--..-----------__ ❑ Number of pits--------------_-----Lining material--------.--------------Size: Diameter---..._.---------------Depth--------------------------------- Cesspool: Distance from nearest well-----------------Distance from foundation-------------------.Lining material------------------------------------- El Size: Diameter-------------------- -----------------Depth----------------------------------------------------Liquid Capacity _gals.T Privy: Distance from nearest well----------------------------------------- - -----Distance from nearest building---------------------------------..------. ❑ Distance to nearest lot line---------------------------- ---- -----------------------------------------••----------------------------------•--------------------•-------- Remodeling and/or repairing (describe):--------------------------------------------------.--------------------------------•-•--•-----------•--••-----------•--•---•---------------------------- _------•_••-----_.----_•-••-----•--_--_--•"-------------- '---T------- ----------•••------•-•-----------`--.........-------------------------------•------------------------------------------.--------------------------- ------------------------------------ - I hereby certify that I have pre red is applica on and that the work will be done in accordance with San Joaquin County ordinances, State laws, and rules an regul ions of t San Joaquin Local Health District. b (Signed). ---- - -- ----------------••--------------------- ---------------------------...(Owner and/or Contractor) By:----------------------......... -- ---- --------------------;----------------------------- -----(Title)--------------------------------------- ................ (Plot plan, showing size of I , lt� oceti n o system in relation to wells, buildings, etc., can be placed on reverse side). i OR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY--------- "` -----------•--•----------------------------------- DATE.............. r'� G REVIEWEDBY---------------------------------------------- - ---------------------------------•--------------------------------•------- DATE---------------.-...--•----------••----•---------------...- BUILDINGPERMIT ISSUED----------------------------•---------------------------------___---------------------------------- DATE--------------------------------------•------••------------- Alterafion,and// recommendations:-------------------------------------------------•---•-------------•-----------•-••----------------•----------------------------------------------------------- rP._..�� G- ! `� ✓c .. G �S-------------------- -------------------------------------I--------------------------------------------------------------------------------------------------------------------------I------------------------------ ---..-. ------------------- ----------------- --------------------- -- ---------•--•------------------------------------- FINAL INSPECTION BY:..----- p- ----------- Date---------------e"it I -------------------------------- SAN JOAQUIN 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 E5 9 REVISED 8-59 2M 5-62 ATLAS