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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 instasawm This application is made in compliance with County Ordinance No. 549, ascribed. JOB ADDRESS AND LOCATION-__---_ . -_ 1 i Ij 1 ----- . ^` tc 4i,� t ``_t,j 1- --L-'--------------------•------...---.- Phone_�.L':_: '..' Address.................. - Owner's ame____________ ___4_�__ U . - l Contractor's ---------------------•--------- ------------ ------_----- Installation will serve: Residence [DApartment House ❑ Com -mercial ❑ Trailer Court E] Motel ❑ Other [I---------------- Number of living units: ---I--- Number of bedrooms 4._ Number of baths ---I... Lot size _._.. GU' }� Water Supply: Public system � •---Y © Community system ❑ Private ❑ Depth to Water Table ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe "Hardpan ❑ Previous Application Made: (If yes,date--------------------) No [g ' New Construction: Yes TYPE OF INSTALLATION AND SPECIFICATIONS: © No ❑ FHA/VA: Yes ❑ No [a (No septic tank or cesspool permitted if public sewer is available within 200 feet.) ' Q�Septic Tank: Distance from nearest well-----------------Distance from foundation---_.--_-_ C'..>� . .•.;j No. of compartments----------------------- -------Material------------..................................... -- Disposal Field: Distance from nearest well ---Size----------- . ---Liquid d -• epth_-- -•-------------------Capacity__-_"._---_--."-" Number of linesDistance from foundation------------_-----Distance to nearest lot line._............. `❑ l� ___ ____________Length of each line_____-------_-_- Type of filter material------------------ Width of trench...-.._..-..._.._.__............... Depth of filter material-----------------------Total length.-----------------._-___-_____-•---__-_--_ Seepage Pit: Distance to nearest well4�� Distance from foundation..._1__C-t__-. Distance to nearest lot line.__:S_-_.--.._ ry El Number of pits--.-.-)---------------Lining material.__ _ �--.��- Size: Diameter._- ?-is?-- _____Depth.-:{_.�--`_-,-_.'.�.-,.� b Cesspool: Distance from nearest well•--------------•_Distance from foundation-----._----..-----..Lining material-..-_-_......_.._...._.......-__.___ ❑ Size: Diameter-----------------------------------_-Depth---------------------------------- Privy: Distance from nearest well------ quid Capacity'-'--------------•--------•-gals. ❑ Distance to nearest lot line-------------------------------- � -------------------Distance from nearest building-__._--___-_---___•_.__.__._•_--__-_-- __--_________________ __--__-.Li --------------------------------------------------------------- Remodeling and/or repairing (describe):---------lto �t4 r�t � ---- ........................ (( r 4 f Tk I, �t > �� (Q .. ..................................-- -••------_-----_-- �� --`r-----• ---•--•.. �•------a i - --------•---------•-------------------• ---- -•---•----------------------------------- I 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. �' (Sig reed -- ----- ----------------- ........(Owner and/or Contractor) BY:------. -`- i t = - (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---•_�---____- REVIEWED BY------------- - ----------- �.�.-------------------------------------- DATE----� .... �"- ----- BUILDING PERMIT ISSUED. ---- DATE ---•- ... ---------------------------------- ------------------------ •--•--•... DATE.----------------------•------------•-- Alterations and or recomme dations------------------- " vZ _ ------ . _ n �_ --•-- •---• ••-•-----••- FINAL INSPECTION BY:------ Date --^----- ----------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 144 Sycamore Street Stockton,California Lodi,California 405 West 9th street Manteca,California E6 9 REVISED 6-69 2M 3.61 ATLAS Tracy,California