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FOR OFFICE USE <br /> --------------- <br /> _____________r------._.---__-.___-____.---__-___-_- APPLICATION OR SANITATION PERMIT Permit No. <br /> ------------- --------------------- (Complete in Duplicate) <br /> Date Issued ............ ......... <br /> -----------4 This Permit Expires I Year From Date Issued �//7 <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described. <br /> This application is made in compliance with County Ordinance No. 549. <br /> JOB ADDRESS AND LOCATION__�_,721----4-0-----Qe7l�__ .... ... ........................................................... <br /> Owner's Name.._-Idlm .......... ............................................................... ............................................. Phone.--•-•----........ <br /> Address..--- <br /> ......... .... <br /> Contractor's Name...... <br /> .................................................................................................. Phone............... <br /> Installation will serve: Residence [Apartment House E] Commercial F] Trailer Court 0 Motel 0 Other ❑ <br /> Number of living units: -r_.__. Number of bedrooms _3__- Number of baths J.... Lot size .............................. %ftt3I <br /> Water Supply: Public system 2---Community system [] Private [] Depth TO Water Table ZO ft. <br /> Character of soil to a depth of 3 feet: Sand E] Gravel F] Sandy Loam E] Clay Loam El Clay 0 Adobe 0-'fi..ardpan 0 <br /> Previous Application Made: (if yes,date-------- _--------) No Rr-""New ConstructioA': Yes �o E] FHA/VA: Yes El No e <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> (No septic tank or cesspool permitted if public sewer is available within 200 feet.) <br /> Septic >nk: Distance from nearest well--P---...Distance from foundation/P- .........material_ �. ................... .............. <br /> -_ ---------------- <br /> [Roo No. of compartments____.?_________________Size___.__3_AYX_ ....Liquicldepth_ . Capacity......kjQQ 4 <br /> Disposal,Field: Distance from nearest well----------Distance from foundation,/A..............Distance to nearest lot line..`5 <br /> 031" Number of lines_....___ -----------Length of each line...7(5------------------Width of trench..��$P_*..................... <br /> a .. <br /> Type of filter mate - --------Depth of filter material...1.k----------------Total length.... ........................... <br /> r <br /> Seepag Pit: Distance to nearest well---,-— _---_-__-__Distance from foundatiodO................Distance to nearest lot line ........ <br /> 7, Number of pits----A............Lining mate rialITO Size: Diameter_.33_7---------Depth.------AW................... <br /> Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material........__...__....................... <br /> 0 Size: Diameter--------------------------------------Depth----------------------------------------------------Liquid Capacity............................gals. <br /> Privy: Distance from nearest well-------------------------------------------------Distance from nearest building___......._____.........._................ <br /> 0 Distance to nearest lot line----- --------------------------- <br /> Remodelingand/or repairing (describe):---------------------------............................................................. ........................................................... <br /> ............................................................................................................................................................................................................................. <br /> .................................................................................................................................................................................................................------------ <br /> ----------------------------------------------------------------................... ..................................................................................................................................... <br /> I hereby certify that I have prepared this licatigfi and that the work will be done in accordance with San Joaquin County <br /> ordinances, State laws, and rules and regulaii of f San Joa Local Health District. <br /> I <br /> (Signed)--------------------- ------ ---------- ----------------------------------------------------------------------------------------- i-f----------------------(Owner <br /> --------------------(Owner and/or Contractor) <br /> By:.................. . <br /> (Plot plan, showing size of lot, location of system in relation for wells, buildings, efc., can 69 placed on reverse side). <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY-------... ....................................................... DATE------. <br /> REVIEWED BY............... --------------------------------- <br /> ........................ ------------------------------------------------ ----------- .................... DATE...................................................... <br /> BUILDINGPERMIT ISSUED................................................................................................... DATE............................................................. <br /> Alterations and/or recommendations:..... <br /> -Cj j;;j-.-7;.:Y----------------------------------------------------------*------------ ----------*-------*-------------*-----------------------------­........ <br /> ...................................................�� ---�c . ....6>1<1 .......................e�;�F......... . ................................*-----------*------------- <br /> ........................ <br /> ...................7 .7:�: ..... ------- <br /> ............................................................................... ----------.­------------------i�................................................................................. <br /> .................................. --------------------------------------------- ............................................................................................................................................. <br /> FINAL INSPECTION BY:. (57 -------------_------ Date------ 2- r <br /> ............................................. ........... .............. <br /> SAN JOAQUI N LOCAL HEALTH DISTRICT <br /> 130 South American Street 300 West Oak Street 124 Sycamore Street 205 West 9th Street <br /> Stockton,California Lodi,California Manteca,California Tracy,California <br /> 95 9 REVISED B-59 2M 5-62 ATLAS <br />