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FOR OFFICE USE: � -- '1' Z9.�T 6 9 APPLICATION FOR SANITATION PERMITA4`— 57�Permit No. .., --------------- --- - (Complete in Duplicate) Issued ------------ ------- ---- -- ----------- Date Issued ---•_--.------ ___ ___ _____________..._._---__._..____.___._____..__ This Permit Expires 1 Year From Date ssue 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. /1 JOB ADDRESS AND LOCATION...../-__)W' - ----- ��.... f "' Owner's Name---,-��------- t�----rte ---- .-- ------------------- ---- ------ Phone------------------................ Address•-------• �I_'t.d 1•, r• A.,Z-------------------------------------------- ...••----------------------------------..--------------------------•-------------•-••--•--------- Contractor's Name...------ -------- -----•-----------------------------•-•------------•----- Phone Installation will serve: Residenceu, Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ s Number of living units: ___• Number of bedrooms Number of baths 4.... Lot size Water Supply: Publics stem ❑ Community system tDepth TWater Table ft em ❑ Private epo _�- . (/ Y � .�� Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe 1� Hardpan ❑ Previous Application Made: (If yes,date____________________) NoX New Construction: YesX No ❑ FHA/VA: Yes ❑ No j� TYPE OF INSTALLATION AND SPECIFICATIONS: 4 (No septic tank or cesspool permitted if public sewer is available within 200 feet.) N r Septic Tank: - -Distance-from nearest well--_�-__c._Distance-from-foundation______________-___.Material::____ _.__ __ - - • ' No. of compartments--------------------------Size--------------------------------Liquid depth--- _Capaci �,2E�b al Fiel Distance from nearest eII__!'j_')'___-. -Distance from foundation.._ .JQ:..._._.Dist,�e to nearest lot jint�_______________ s Number of lines__..__ Length of each line_.`_ _ _- ' ith of trench._._ _7"_._...._______.... • -------Total length------tb.2------------•---------- Type of filter material. �" F Depth of filter matenal____l_ �� Seepage Pit: -Distance to nearest well---------------------- 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. `-- Priv ' `-- ._Distance from nearest builijiri Y Privy: Distance from nearest well------ -------------------------- ----- ---- 9------------- -----------------------� ❑ Distance to nearest lot line-------------------------------------------- -----------------.......-------------------.---------------..------- --••--------------- Remo ling and/or airing d cribe�' i. - cp - • ---- 2� - - - -_J--- ----- -_--------------------------------------------------------------------------------------------------------------------- I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, res, nd r sand regulations of the San Joaquin Local Health District.(Signed)_ f --- ---------- - {Owner end/or Contractor) By:------------------------------------------------------------------------------------------------------------------------------------(Title)...------- ---------------------------- -----..-------- (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 APPLICATIONACCEPTED BY------------------------------ ------------------------------------------------------------------ DATE--------------------------------------------_------------ REVIEWED BY--------------------------------------------- ------------- DATE----- } 7� BUILDING PERMIT ISSUED.... -----------------_-------- DATE------- --------------------------- ------ Alterations and/or recommendations:-------------- ---------------------- -----------. --------------------•----•--------•--------------•--•--•----------- -•-•--•--.-•------------------•------------ ---------------•---------------- ----------------------- --------------•--•---------------------------••-----------------------------....----------------------------------------- ----------------------------------------- - ------ -- ---------------------------------••---------------•------------------------ ------------ -------------------------- FINAL INSPECTION BY--------------- ----- - Date------. --------------` _ ppf SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak�Srr�`pet 124 Sycamore Street 205 West 91h Street Stockton,Call fornia Lodi,California � Manteca,California Tracy,California ES 9 REVISED B-59 2M 5.62 ATLAS