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I-UK UH-JU E{ -------------- - ------------------------- APPLICATION FOR SANITATION PERMIT Permit No. ...,f .` � ----------- --•----------------------------------------- (Complete in Duplicate) 71 -------------- --- This Permit Expires 1 Year From Date Issued Date Issued .__-...-___.-•-.__---3. 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-_. --- ----- Owner's ---Owner's Name... .-.- '-- ---------------------------- ------ Phone_�.�. Address....................... Contractor's Name....... ----------------------------------- --------------- Phone................................... Installation will serve: Residence D--`A�partment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: /___- Number of bedrooms ___:-Number of baths __4.__ Lot size ___-_ ........�___'_............................... Water Supply: Public system ❑ Community system ❑ Private 2— Depth To Water Table ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe Hardpan ❑ Previous Application Made: (If yes,date....................) No New Construction: Yes K?--Ko ❑ FHA/VA: Yes ❑ No R--' TYPE OF INSTALLATION AND SPECIFICATIONS: -• (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic nk: Distance from nearest well_A __.__Distance from foundation_____/G____ -Material.lo-- -- t� .�.-- - 2e �-- �-� -ui!No. of com artments----------Z�-------Size_... Li Liquid de th_------ .._ ' - i Disposal Field: Distance from nearest well 4c_____._Distance from foundation____ ___C2___.....Distance to nearest lot ling•_•.- ._-. Number of lines------_---------�-----------Length of each line..........4--V. Width of trench----- -- �,r..-----•----•--•--- Type of filter material._._. _11 .__Depth of filter matenal._..._l�''_ _____-Total length_____�..:�_____________ _____________ 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-,----------------------------------- 11 Size: Diameter--------------------------------- ----Depth__.------------------------•------------------------Liquid Capacity-------_------------------gals. Privy: Distance`.from nearest well------------------------- ---._- --------Distance from nearest building------------------------------------------ F7 ti Distance to ne . est'lot line `----------- ' --------------------------------------------------•-----------------------------•--------------------- Remodeling and/or repairing (describe) I---------------------%--------=--- 1-------•--------------------•---------•--•--• ----••---•--------------•-••----•---•------------------- ---------- -------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- I hereby certify that I have prepared #his application and that the work will be done in accordance with San Joaquin County ordinances, State laws, and rules and regulations of the San Joaquin Local Health District. ` .1�3.—.. n.� ............. --------------- --------------------- - --- --- _ _______________________{Owner and/or Contractor) By:---------------------- -- Title (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). + w % FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY_-' _------�.t-1— J-------------------------------•----•--------------- DATE- � '= REVIEWEDBY--------------------------------------------- ---•- -1------------------------------------------------------------------------.- DATE-------•----- BUILDING PERMIT ISSUED--------------------------------------------- --------------___-------------------------------- DATE-----•-•----....__.--------------------------- Alterations and/or recommendations:----------------------------- --•---------------------------------_...------------------------------------....... - h ........................................`--------------------------------------------------------------------------------------------------........------------------------------------------------.-------------------------- --------------------------------______________________________________________________________________________________________________________________________________________________________________________________________ ____________________________________________________________ 5 FINAL INSPECTION BY:------ ---------------•---------------- Date..--- -4P�_: -r_,_;2. -` --------- t -SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Strout 300 West Oak Street 124 Sycamore Street T 20S Wart 9th Strout Stockton,California Locil,California Manteca,California Tracy,California ES 9 REVISED a-59 2M 5-62 ATLAS 1w,iz