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FOR OFFICE USE: 3c• r�a4 ------------ ------------------------- . -. - ------------------ -------------------------------------- APPLICATION FOR SANITATION PERMIT Permit No. ..../.5..��. .... • •1 -------------------------------------------------------- (Complete in Duplicate) / Z Date Issued -- --- This Permit Expires 1 YF:sr From 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_- _ �� L�/✓e�i f fiy,o 7,'1,,e /kms Owner's Name-------1.&0--------V<------ f1lyT 3'.. - R Phone 'S.70.• Address 5z r�------------------------ •- -- ---- Contractor's Name--------I� r�-:.. f`t !' /•S/ ---�---SNf----- =azn�m) one. r Installation will serve: Residence 0' Apartment House ❑ Commercial ❑ TraileNumber of living units: __/__-_ Number of bedrooms --3._ Number of baths 1-.-- -��447s'.................... Water Supply: Public system ❑ Community system ❑ Private E�' Depth To Water Table -------- ft. f Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam [`_Clay Loam ❑ Clay ❑ Adobe[] Hardpan ❑ i Previous Application Made: (If yes,date-------------------- No ET' New Construction: Yes ❑ No [T__FHANA: Yes ❑ No TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tank: Distance from nearest well---------------.Distance from foundation------------------ Material----.---------._.-.-_-_----_-------------------. ❑ No. of compartments--------------------------Size------•-------------------------Liquid depth-------------- --------Capacity----------------------- Disposal Field: Distance from nearest well__1S7 ....Distance from foundation--_--/--Q- .......Distance to nearest lot ey,.5 iNG Number of lines............/---------------------Length of each line--------:. - -----------Width of trench--------�g__�,L......-......... r4�p Type of filter material._,F!7! ------.---Depth of filter material------- `-"----.-Total length-------------- ._'...._......-..-- Seepage Pit: Distance to nearest well__ __w--_-__--_--.-.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--------..----------.-------__----__- IJ Size: Diameter-------------------------- --- -----.-Depth-------------------•--------------------------------Liquid Capacity----------------------------gals, Privy: Distance from nearest well----------------------------------------------_-Distance from nearest building--------_-.__---_-----....._--------.---_. ❑ Distance to nearest lot line - Remodeling and/or repairing (describel:-------f}blp_......_7V--------�;rZ.5/!!�-r'-_._- Y ---------------------If .--•-------------••--------....-...----------------------------•-----------------------•--•---- --------------------•----------------------------------------------------------------------------------------------- -------- ------------------------------------•------------------------------------------------•-••--------------...------•-------•-------------------------•----•---------------------•-----•--------._.---•----------------- I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin Counfy ordinances, State laws, and rules and-regulations of the San Joaquin Local Health District. (Signed)-------—ZQ_a �� ------- --------------------------------(Owner and/or Contractor) By: Q (Title)----------= - (Plot plan, showing size of lot, locatio of system in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY---- ` --------------•----- -----------------------.- DATE----�/... - REVIEWEDBY------------------------ ---- ----- ----------------------------------------------------------------•--------------- DATE------------------ ..... BUILDINGPERMIT ISSUED----- -------------------------------------------------------- ------------------------------------- DATE------------_--- --------------------------- Alterations and/or recommendations:----------------------------------------------------------------------------------__...............-•---------------.....----.....---•---•------------•------ ---------------•--------------- -- ---------------•----------------------------------------------------------------------------- ----•---.. - •--------------------•••--------------••---------------•------------ FINAL INSPECTION BY:.------1_ 1 , = Date - .:. SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 124 Sycamore Street 205 West 91h Street Stockton,California Lodi,California Manteca,California Tracy,California ES 9 REVISED 2-59 2M 5-62 ATLAS L