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FOR OFF 11`11: --- - . ---------------- APPLICATION FOR SANITATION PERMIT Permit NO. l°, ---------------- ----------- ------------- ---- - {Complete in Duplicate) ---- .y This Permit Expires f Year From Data Issued Date Issued ._ �Al� 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 LO TION-. _76-yam ~ ! ---•--------------------------------•-------------•-------------••----------------- • .................. Owner's Name----------••• ' -----•---• -------•-•----------- ----- --------------- Ph6ne.................................... Address......113• - ----------- --- G!r` -----------••--------- ---•- Contractor's Name �S ------------------------------------•-•-_..... Phone................................... Installation will serve: Residence 0 Apartment House ❑ Commercial [_1 Trailer Court ❑ Motel ❑ Other ❑ Number of living units: __I-___ Number of bedrooms,,___ Number of baths _1____ Lot size _.AB _x_Ss` Water Supply: Public system Community system E] Private ElDepth 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--------------------I Noe New Construction: Yes eNo ❑ FHA/VA: Yes ❑ No E--- r TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tank: Distance from nearest well___ _--Distance from foundation_1o___ ---Material-__--1`".______ \\ L� No. of compartments__-.e�--------------_Size_,3_XS-�-•7-----Liquid depth-----_f�._-.------•-------Capacity.....P'a_j' Disposal.Field: Distance from nearest well_._-----Distance from foundation/f.-` ..........Distance to nearest lot line.147- r Number of lines.______$ __ Length of each line------ of trench._�f'_-�- ---•----------• --- Type of filter material._._ _CA•_________Depth of filter material__1U -----------Total length___e 'T_o.`-----• ---------•-• Seepage Pit: Distance to nearest well--=----------Distance l _r -___Lining materaal._ rem f 7..____._ .._.Distance - ____.Number of pits_-_�.______ _ -_.._size: Diameter---s� .-�_ .__ '~ -----a - --,Depth------�`�---•-------------- Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material__.--_____-----_______-...______-_. ❑ Size: Diameter----••--------------------------------Depth----------------------------------------------------Liquid Capacity-----------------•----------gals. Privy: Distance from nearest well----------------------------------------- from nearest building ❑ Distance to nearest lot line_________ Remodeling and/or repairing (describe)_______________________ --------------------------------------- ----------I--------------------------------------------------------------------------------•-•--------------------------------------------------------------- -------------------------------------------------------- I hereby certify that I have prepared this a - licat. n and th t the work will be done in accordance with San Joaquin County ordinances, State laws, and rules and regulati of a San Jo quin Local Health District. (Signed)------------- •---------------•-- ------------ ------•-- - -----------------.(Owner and/or Contractor) By:...........--------------------•----- ----- ---------------{rtle)---------------------------------------------------- . --------- (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY------ REVIEWED BY ----- - . -. DATE. BUILDING PERMIT ISSUED ------------------------ ----------- DATE Alterations and/or recommendati ns•.____ __ ----------- ......................... 3----- , --------------------- - - f .. ------------fir r.�_P.�j._�.., _ �' -- -------- 7-16 FINAL INSPECTION BY:-.-----. f- .��4— --------------------------- Date--------,(-`�� SAN JOAQUIN LOCAL HEALTH DISTRICT ]30 South American Street I 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,California Manteca,California Tracy,California E5 9�RtVISED 8.59 2M 5-62 ATLAS