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FOROFFICE USE: --------------------- ---- ----- APPLICATION FOR SANITATION PERMIT Permit No_ ____ __________________ , 3 u i A------I-l .------------- (Complete in Duplicate) �L_6 c ------ This Permit Expires 1 Year From-Date Issued Date Issued .1...�............. 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. 3(31 J5 . JOB ADDRESS AND -------- LOCATIO -_--••-;-------- --uf, ---•--__-••vL -- Owner's Name... .. �J" ^' `�??�Q��t ---��r_ Phone. Addressy--------- -------• -------•----•.......--•-------------------•-•-------•-----...---•-----------••----••-...... ...... .........••--•-----•- Contractor's Name------ --•-- -----•---- ------- _---•--------------------- -----------------------------------------...................__ Phone, ,S7�'16®-7--- Installation will serve: Residence ❑ Apartment House ❑ CommercialTrailer rt ❑ Motel ❑ Other ❑ Number of living units: -------- Number of bedrooms -------- Number of baths__ __ of size --- [r1-- ....1_. ------________ Water Supply: Public system ❑ Community system ❑ Private ,Depth to Water Table4 ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe 2TIP-ardpan❑ Previous Application Made: {If yes,date-------------------- No ❑ New Construction: Yes 21<❑ FHA/VA: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) i" ) Septic Tank: Distance from nearest well_- -r_._DistA9 j af cue fror4 foundation_ ©_-�__. �t�rial-- J� �........... ...................� No. of com arfinents-____ ___ ltz__ _ _ _ ...Liquid depth___---------------------Capacity- P C�------ Si,SIz Disposal Field: Distance from nearest ...Distance from foundatpipn._R-© .......Distance'to nearest lot line....,:51. ❑I' Number of lines.........t2------- - ---------_Length of each line----(Q -- --r_i_--...Width of trench.. ;?V.��--•-.----..-_-- Type of filter material._ i__ (2 ' Depth of filter material-. _.I --------Total length.-- Seepage Pit: Distance to nearest well-/c©__________Distance f om d --------iisfa5p to nearest lot line... ------------ Number of pifs___'/--- .------Lining materi I--- - ---- -------- ' e: Diameter.__ _3-------------Dept h------ ---------- Cesspool: Distance from nearest __ __________Dista c� om f d tion__-_-.-------------.Lining material......................--------------- ❑ Size: Diameter------------------------ ----------------- - Depth-- --------qd-------------------------------------Liquid Capacity-------------...............gals. Privy: Distance from nearest w II_________ -----_-�_.______tl.0-------Distance from nearest building------------------------------------------- ❑ Distance to nearest lot li --------- ---------- ------------ - -----------------•--------------•----•---•----_-------------------• Remodeling and/or repairing (describe):--- I C - A ---------•------------------------------•-------------------------• ....... - ---------------•--------------•--------------•---- - y � / - ----reb; tify and rade and red •ions li the San Joaquin Local Health District. Sa - my I hereb rti hat I have repared lice+ion and that the work will be done in accordance with San Joaquin County ordinances, at __ 4 (Signed)............. - ------------..................... ----- ----- { nor and/or-Contractorl IN (Title)----- ------------- ------------------- (Plot plan, showing size of lot, location of ys+em in relation to Is, buildings, etc., can be placed on reverse side). i« FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY. ------ ---/----------------------- DATE 1 -" f•--------••------------- , REVIEWED BY.... -------------- / DATE BUILDING PERMIT ISSUED.-----•--•-----•-------••----- ------------••------------------------------------------------------- DATE-_-------------------•--•- a Alterations and/or recommenclations----------------------------------------- --- ---•----.._---_----- -- _ --- --------• - ------- •. � tf _ ri ------------------------- ---------------------------------•------------------------------------------------------------ -•----•- --- ----- ----------------------•--------------------•----------- •---------- FINAL INSPECTION BY:-- 'JJ.?.t.. -- . --------- - Date.-.. ---------- 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 ES 9 INEVISED B-89 2M 11-61 ATLAS