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FOR OFFICE USE: -------------------------------------------------------- ________ ___________ ______________________ APPLICATION FOR SANITATION PERMIT Permit•No. ...P`..R....... ------ (Complete in Duplicate) 0_(_7 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 an stall the work herein described. _.- This application is made in compliance with County Ordinance No. 549. - s- JOB ADDRESS A D OCATION...... -- ----- -- - ....�_ ....__..._. ------ Owner's Name - - -- ------ Phone--_ .._.. Address.•-------•-•-... Contractor's Name--- ---------------••-•-----------•------------------------------------------------------------------------------------------------------ Phone................................... Installation will serve:Residence Apartment House Commercial Trailer Court Motel 171 Other Number of living units: .....r_. Number of bedrooms J� Number of baths ...i--- Lot size .........i.................k�n............. Water Supply: Public system Community system ❑ Private ❑ Depth To Water Table ........ ft. Character of soil to a depth of 3 feet: Sad rl J Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe 0� Hardpan ❑ (� Previous Application Made: (If yes,datg_ _--7tt _No E] New Construction: Yes E] No ❑ FHA/VA: Yes ❑ No [ w TYPE OF INSTALLATION AND SPECIFICATION (No septic tank or cesspool permitted if public sewer is available within 200 feet.), Septic Tank: Distance from nearest well... Distanc�e� from foundation._._./ ) Mat real----------'� --- L .may, No. of compartments------ ':--_-__-.Size----` '�:..r_1 _Liquid depth--------- ----------------Capacity------ i-U. `-'-j. Disposal Field: Distance from nearest well_- --_-__--. Distance from foundatig ____l.�__._....Distance to nearest lot line...r r----------- Number of lines_____________ _______ ______ Length of each line' 5.. Width of french-__---_-`2-9_ --___ LLnn - t Type of filter material—...4�=1��K'Depth of filter material____.tA------------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............._....................... ❑ Size: Diameter--------------------------------------Depth----------------------------------------------------Liquid Capacity............................gals. Privy: Distance from nearest well_________________________________________ _______Distance from nearest building.......................................... ❑ Distance to nearest lot line-----------------------------------------------------------------------------------•------- ......................................... Remodeling and/or repairing (describe):--------�/-��,> _n �QC (�I -c -------n--k .�2 �( e=-� ------------•-----•------•------•-----------------•-----------------------•-------•---•----------------------------------I. ------•--••--•------------------•-•------------------------------•-----------------------•---------------------------------------•---•-------------------------•-•••--•-•-•••--•---•-------•-------......._..-•------•------- ----------------------------------------•---------------•--•-••---•.••-------•----•------••------•---•---------•-------------.-_----------.---••--_--.-------_-..-----•----•-.-----------.......-----...----.------_----.--- 1 hereby certify that I 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)-----� -- -------------------- --------------------(Owner and/or Contractor) (Plot plan, showing size of lot, location 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:..__ ------(0.'5 QAA' ,c.•-1sK. t i•_ -------------------------------------------------------------------------------------------- .............................. s- ----------------------------------------------•------------------------------------------ -------------------- ...............-..................., .................................---................................ ------------------------------------------------------------------------------ ------ ------------------------------------------------------------------------------------------------------------------------ FINALINSPECTION BY----- ----------------------------------------------------------- Date....... ..............................................................•----•--- ' `f f - SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South Amorl S oif 300 Wast Oak Street 124 Sycamore Street 205 Wast 9th Street Stockton,California Lodi,Callford%_— Manteca,California Tracy,California ES 9 REVISED a-59 2M 5-62 ATLAS