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FOR OFFIC USE: I� _ l __-_ __.____..___1I.-.. APPLICATION FOR SANITATION PERMIT " Permit No. I.. .... .1....� ' ---------------------------------------- 11 (Complete in Duplicate) ------------------------ ---.-!��.--- This Permit Expires 1 Year From Date Issued Date Issued . This v Application is hereby madeto the San Joaquin Local Health District for a permit to construct and install the work herein described. This application is made in lompliance with County'Ordinance No. 549. JOB ADDRESS AND L CA� TIO _ -3P _________________ ------------ -------- --- --- -------------------------- Owner's Name........ __J----- ------ Phone----.._------------------------ Address-_. ------------------------ Address_. ._---- F e Contractor's Name------------ 6--- ••-•--- ' T------------------------------------------ Phone Installaton will serve: Residence �partment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ F Number of living units: _4____ Number of bedrooms __3 Number of baths __/____ Lot size ..`~.?� �--,��________________________________ Water Supply: Public system [-] Community system [:] Private ❑ Depth To Water Table _!Oft.Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sa dy Loam ❑ Clay Loam El Clay F1 Adobe[�Fiardpan E]Previous Application Made:] {lf yes,date--------------- No New Construction: YesNo [I FHA/VA: Yes [ 'No E];I� TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public,sewer is available within 200 feet.) r Septic T Distance from nearest well_"--_____Distance from foundation_---_____________Vateriai__�.-------------------------.____ No. of compartments_______ ______________Size..._..-3YSX9_:__.Liquid depth___ __--____________._Capacity_____, ---li)rz Disposal Field: Distance from nearest ell_-'�____---Distance from founds Distance to nearest lot line__��__. -- I Number':of lines..... _ _._______Length of each line___ "_________________Width of trench._..-_: .. y Type of;filter material-_ e_-______Depth of filter material__ __b_ _____Total length.......`.' �Q..: . .. Seepage Pit: DistancIII e� to nearest e11 -----------Distan fou tion__S.�_�.___........Distance to nearest lot line--J—I/ Number pits------- -----Lining material---- -- ------- --5 e: Diameter------- -�`--Depth--------- - ---------- Cesspool: Distancle� from nearest well_________________Distance ------------- Lining material--------------------.-_...__-___-.... .,f. El Size: Difameter--------------------------------------De th----•---------------------------------------------__Liquid Capacity gals. Privy: Distanct from nearest well-------------------------------------------------Distance from nearest building.......-----------........................ ❑ Distanct to nearest lot line-------------------------------------------------------------------------------------------------=--------------------•-••-------------------- Remodeling. and/or repairing (clescribe)---------------------------------------------------------------------------------------------------------------------------------------------------------- ---------------------------------------------I11: ��' ---•----•--•-------•--------------------•-----------------__----____---••---------••----------•----- --- 1 I hereby certify that Iave prepared this a lica ion and that the work will be done in accordance with San Joaquin County '" ` ordinances, State laws, and rules and regulati 0 e San Joaquin Local Health District. I � (Signed) -- - -------- --------- --- ---------------•------------- -------------------------------------...(Owner and/or Contractor ------------- By:..............................11 --- --- ---------------------- (Title)__-__-------------------------------------------- ---------.._.. (Plot plan, showing sire of lot, location of system in relafion to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTEDI BY-- - ------ ----------------------- ----------- DATE- Z-------------- f - ---- - REVIEWEDBY---------------------�M----------- -------- -------------------------------------------------------------------------------• DATE_----------------------------------------------------- ---_- BUILDING PERMIT ISSUED------------••- --•------------------------------- ---------------- ---------------------------- DATE---------------------------------- ------------••-•----------- Alterations and/or recommendrati0 s---- ------------------- ----*----_-.----------------___-- --------------____--_-- _-- t I -- -------------------------------------------------------•-•---------•----------------------------------------- ----------------------------------.._.... ..... .... - Il-. IM FINAL INSPECTION BY ----- ---- ------ Date-.-. :�, -`J �{ `"--- �-------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Symet 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,California Manteca,California Tracy,California ES 9 REVISED 6-59 2M 5-62 ATLAS