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FOR OFFICE USE: 77 ------------------ APPLICATION FOR SANITATION PERMIT Permit No. , .� .. .� ------------------------------------------ -------------- (Complete in Duplicate) ----- This Permit Expires 1 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. I JOB ADDRESS AND LOCATION__�__----------- .---•- S-a- --•-• ----!G -w-�VF--- --- ---- ��y0�1 , y-` ........7-------- Owner's Name------0--..... --------•-�-----••---------------•---------------------- - --------------------------_-----•-----•--- Phone..---------•---•-•----.----.._....� Address.....------.1�--Q.1 _.... !_ �3`=`�7 Contractor's Name--•--•------ vary` ' "5. -------------------------------- Phone................................... 1 Installation will serve: Residence ff�'Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ +� P/ 1 Number of living units: ___/__ Number of bedrooms ___�__�Number of baths ---L. Lot size ..._�.,Z._��................................. Water Supply: Public system ❑ Community system ❑ Private Depth To Water Table rl _ ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam Clay Loam ❑ Clay ❑ Adobe ❑ Hardpan ❑ Previous Application Made: I I f yes,date....................) No New Construction: Yes 01"'No ❑ FHA/VA: Yes ❑ No ®� TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) f n Septic ank: Distance from nearest well--- __.__Distancefr�pm founcllafion.-119----.-------Material_-_I-1- ...... __ No. of compartments p SizeX Liquid depth ------ -------- Capacity r .a i Dispos Field: Distance from nearest well_� .......Distance from foundation-/O.. to nearest lot line...` ..�... Number of lines___ ---------�.-----------------Length of each line__-Ll0_-----------_-__-_-_Width of trench-. .-�/--------- Type ---------- Type of filter material,-.` --------Depth of filter material---2t.._.__.....Total length---------/.. ------------------------ Seepage Pit: Distance to nearest well----------------------Distance from foundation--------------------Distance to nearest lot line----------------- ElNumber of pits----------------------Lining material-----------------------Size: Diameter........•---------------Depth----..---..---------..------_-- ' Cesspool: Distance from nearest well-----------------Distance from foundation.----------.--------Lining material................................ ❑ Size: Diameter-------------------------- -----------Depth----------------------------------- ----------•--_-Liquid Capacity----•----------------_-...gals. Privy: Distance from nearest well-----------_----------------------- -------------Distance from nearest building----------...._---_.____----_---_---_----. ❑ Distance to nearest lot line--------------------------------------------- ----------------------------------------------------•-----•-------•--------•-- k"'� t Remodelingand/or repairing (describe)--------------------------------------------------------•-•-•---------•------------••-------.._...-----------------•-----------•------..-----..--------- ---•--------------------------------------•-•---.._.-.-----•---••--------------------------------------------- ------------------------------------------------------•-----------•-----•----------------------------------- r. ---------------------------------------------•-----•........----------------------------------------------- ---------------------------------------------------------•-----••-------------------------------------- I hereby certify that € have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State laws, and rules and r ulaf ns of th San Joaquin Local Health District. (Signed)-------------------------- ------ ... -------------------------------------------------------- ------(Owner and/or Contractor) By:.. = ------ -----------------------------------------------------------(Ti+Ie).... .----------------------------------- --- - ------- --- ----- (Plot plan, showing size of lot, ca+ion of system in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY--- REVIEWED $Y. 'f `", DATE -- 3 --------•--------•---f----------------------------------------------------------------•------••------------- DATE----------------.... BUILDINGPERMIT ISSUED----------------------------------------------------------------------------------------------------- DATE------------------------------------------------------------- ANrafionsand/or recommendations-------------------------------------------------------------------------------------------------------------------------------------------------------•------- ----------------------------------------------------------- ----------------------------- ------------------------------------------------------------------------- ------------------- ----------------------------------------------------•--.....-------------------•---------------•---------------.------•-- FINAL INSPECTION BY:----------- _ ---------------- Date--------- .... � 3 _._ SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak STreet 124 Sycamore Strout 205 Wort 9th Street Stockton,California Lodi,California Manteca,California Tracy,California ES 9 REVISED 8-59 8M 5-62 ATLAS f]