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FOR OFFICE USE: i ------------ S- �--- - 3 v _.___._.___.._ -__________ ________________________ APPLICATION FOR SANITATION PERMIT Permit No."----------------------------- y�_15� ----------------- ------------------------•- --------- (Complete in Duplicate)This Permit Expires ] 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 compliance with County Ordinance No. 549. JOB ADDRESS AND LOCATION---- 17XT----- -------------------- ................. - ---------------••---------- Owner's Name...... _ A ( } .. T------------------- Address.................. _.....1 ..11�l! ..... r Contractor's Name------- 'sC�= = . % 'i�/J ----- -•`F ----s------ ------------------------------------ Phone. 0A'r-+!'.__9..---- Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: __ __- Number of bedrooms .1--- Number of baths -1/___ Lot size ..._ ............................ Water Supply: Public system ❑ Community system ❑ Private e Depth to Water Table 4?-$- 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 ❑ No Er"�FHA/VA: Yes ❑ No ❑ \ ti TYPE OF INSTALLATION AND SPECIFICATIONS: ,t (No septic tank or cesspool permitted if public sewer is.pvailable within 200 feet.) SFptic Tank: NG Distance from nearest well-----------------Dista nce from foundation-___--___ ---------.Material................................................. E] CVSV No. of compartments--------------------------Size----------_------------------Liquid depth--------------------------Capacity....................... Disposal Field: Distance from nearest well-AV-1----Distance from foundation----Z,>__........Distance to nearest lot line..... Apo Number of lines-----.-- 1---------------------Length of each line--------6_Q..............Width of trench........Z9R_---------------- Type of filter material _.;:�>ATOA------Depth of filter material____. ------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------------------------------------- ElSize: Diameter-----------------------------------•--Depth--------------------------------•-------------------Liquid Capacity---------------------------gals. Privy: Distance from nearest well ____..------------------------------------------Distance from nearest building------------------------------------------ 0 Distance to nearest lot line----------------•--------------- Remodeling and/or repairing (describe):------� 'v-------;V7...... _ ------ J!✓ ..........•-----------•--•-------------------------------- -------------------------------------------------------------- ------------------------------------ ----------------------------------•......-.....................---------------- --•----•------------------•-----------•----....--------------------------•---------------------••---••----•------..----. ----------- v ------•--••--------------------•------------•---- ---------------------------------------------------------------------------------•-------•-------•-•-•--------------------------------------------------------------- --- I hereby certify that 1 have prepared this 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. (Signed) `-�---`A`. �/E�i�/ --�---------.-Z/.�-----------•_•---------------------------------(Owner and/or Contractor) By:..............d_0�z----- -------------------•- ---------------------------------------•----MRle)----- -1 •----------.---- {Plot plan, showing size of lot, loc ron of system in relation to wells, buildings, etc., can be placed on reverse side). l FOR DEPARTMENT USE ONLY f APPLICATION ACCEPTED BY__ �^ ;----------•- -••------------- DATE 1(0_27- 4_2--------------------- REVIEWEDBY........--------------------------------- ---"---------------------------------------------------------------------------- DATE------------------- BUILDING PERMIT-ISSUED----- ---- ------------------------------------------ ---------------- DATE---- Alterations and/or recommend'ations:__.___ _ J -• i ....�- --- -- - --- --- -- ------- -----. ----- �- ..c ------------------------ ------------------------------------------ --•-- - ----------------------••-----------------------------...---------------. --------------- ------------------- ------ ---------------------- -------------------------------------•-------------- ---------------- FINAL INSPECTION BY:------ / { -=•-••G�..�-�s�-•-�------. Date--------------- —-------•-•------------------ 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 EB 9 REVISED e•89 2M 5-61 ATLAS