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—�-- — - -- FOR FI E U�E: �y [� b— ----------1-- - r �y cd ---.--------f ' ----------- APPLICATION FOR SANITATION PERMIT Permit No. .-ate .... . f r J ------� [Complete in Duplicafel � r� - ---.--- This Permit Expires T Year From Date Issued Date Issued ... _ 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 comp�ne withCounty Ordinance No. 549. JOB ADDRESS AN LOCA--TION_. __ -------------------------------------Owner's Name------ - - r _ ----------- Phone------------------------------------ Address-------------'--O ` •- � b ----------- ----------------- _ ---------- - �---•----••----------•- ----------- --•------------------------••-- Contractor's Name..---- .._... , ��'``��•......1------------_---_ Phone............-------------------- Installation will serve: Residence [Apartment House ❑ Comrnercial ❑ Trailer Court ❑ Motel ❑ Other ❑ l Number of living units: J-__ Number of bedrooms ._3__- Number of baths _1.___- Lot size .__$p,-2�`-x-_----- ��----Water Supply;Supply: Public system [3 Community systemPrivate El Depth To Water Table _�_0 ft. Character of soil to a depth of 3 feet: Sand E] Gravel ❑ Sandy Loam [] Clay Loam ❑ Clay ❑ Adobe[B--Hardpan ❑ " Previous Application Made: (If yes,date____________________) No ff"' New Construction: Yes [!rNo ❑ FHA/VA: Yes No ❑ ! TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic ank: Distance from nearest well-:'7=----Distance from founclationtt r______..-__-Material.P_____________ ____••__••--••------_-_ No. of compartments_------��-------------Size-------•-As- ------Liquid depth---..:4.-- ---Capacity---. P +r_- - Op Disposal Field: Distance from nearest well__='�" Distance from fou�n-d :� ation. 0._ ce to__..--___rDistannearest lot Number of lines__..:_____ ` -_--.__--___Length oi"each%nep _ -�_"fWidth of french____--_-____-K$f 0•--_-- I Type of filter materia *C__ `r ___ ________Depth of filter material_-I_-r______________Total length------ ?------------------------ Type .___ _ V ` l Seeps Pit: Distance to nearest well-_-7:77.--------Distanc�m foundation_/D'I.....__.__.Distance to nearest lot line__J_./ET .__... Number of pits_-__��_.1_1---------Lining material.--/L &— :.Size: Diameter---3-3--------_.---_-Depth_______.___ZJ''_._____. Cesspool: Distance from nearest well------------------Distance from foundation---------------------Lining material..........------------------_------- El _._-____-_--_____.._. ___❑ Size: Diameter------------ -------------------------Depth-------------------------------- T-----------------Liquid Capacity-.P tY-- ---------•--------------gals. Privy: Distance from nearest well-------------_-----------------------------------Distance from nearest-building------------------------------------------ Distance ____-_._____--.-______.Distance to nearest lot line ; Remodeling and/or repairing (describe)____________________ ---------------------------------------•-------------------------------------------------------------- ------------•-----•-----------•-------•I------------ ------ --- -----------------------••------••-----•--4.0repared ---------•-- - --- -•----•--------------------------------------------------------------------------••------------•----------••---------------- -- I hereby certify that I hared is a lica+ion d that the-work will be done in accordance with San Joa uin County ordinances, State laws, and rre ul o of the S n Joaquin Local Health District. (Signed). --------•-• ----•--- --- --- - •------------(Owner and/or Contractor) �Y� -- - T'i+le{ } ----------------------------- ------------(Plot plan, showing size of lotn o system in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY_ 11-V----- --------------•---------------•-------777777777D REVIEWED BY ------------- DATE BUILDING PERMIT ISSUED------ ---•-------------------------------------------- --.................. --------------------- DATE----------•------ Alterations and/or recomme at'ons:_.__.-_ __ --- ---- � -----------------. .� _�� 7. - --------------- -- 1-7 f/ ---------••------------------- ------------------ FINAL INSPECTION BY:._C __--- - -- -� ��--1 �� �J Date--------- •--- -------------- - ----------- AN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Srroot 124 Sycamore Stmt 205 Wort 9th Street Stockton,California Lodi,California Manteca,California Tracy,California ES 9 REVISED 8-59 2M 5-62 ATLAS r