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FOR OFFICE USE: ----------------- ------------------------------------ � APPLICATION FOR SANITATION PERMIT ' Permit No. qt:........._�7 ....... {Complete in Duplicate) f Date issued This Permit Expires 1 Year From Date Issued Application is hereby made to the San Joaquin Local Heal District # per it�constru a d ' II th wor herein described. This application is made in compliance with County rdi / �S/ JOB ADDRESS AND LOCATION---. .. ✓f: -----..... .� r ....... -------I—............ Owner's Name----•- ----- C� , Wit: ----------- ------ Phone------------------------------ 4-Address -------- -- - ---Address .- - --- 51� q� Contractor's Name--------- --- --------✓�' ----- -------- Phone., -- -- -- Installation will Terve: Residence ❑ 7partmenf House ❑ Co martial ❑ Trailer Court C] Motel ❑ Other E] Number of living units: -------- Number of bedrooms -------- Number_of baths -------- Lot size ______________________________________________-_______-____ Water Supply: Public system ❑ Community system ❑ Private ❑ Depth To Water Table ________ ft. i 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 ❑ New Construction: Yes ❑ No ❑ FHA/VA: 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-------:----------•--•- Ile Disposal Field: Distance from nearest well----SW------Distance from foundation....l _---_-..Distancb�to nearest lot line.... ........ Length of each line________ rte, Number of lines.......... _ -_ g _Width of`trench.___r.�.�___:__,�........ Type of filter material-_-_ --_-Depth of filter material___,/`____..___"Total length_--- ..1 .. ____.__... Seepage Pit: Distance to nearest well__A147__ _-.Distance from ndation_/Q :_.Distance. o nearest lot line___!�. Number of pits------oZ-----------Lining material__— --- � +gr- _......� e 3-, --'-_Depth__. AZA57.--•---._._.... Cesspool: Distance from nearest well-----------------Distance from foundation-------------------.Lining material-._;_---------...__-___•-____________ i ❑ Size: Diameter--------------------------------------Depth----------------------------------------------------Liquid Capacity-----------------------------gals. Distance to nearest lot line------------------------------------------------------------------------- nearest building--___-----_-___-._------__-------------- Privy: Distance from nearest well-------------------------------------------- El Remodeling and/or repairing (describe):------------------------------------------------------------------------------------------------ .........---•- --•---------•.............•-- y _ I. hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County 3 ordinances, State law/ss,, and rules and regulations of the San Joaquin Local Health District. ' (Signed).-----------------C !----- 'i/ oog�1. 107 1. {Owner and/or Contractorl By:------------------------------------------------------------------------------------------------------------------------------------{Title)------------------------------- --------- (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). M- FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY_ -------------•---------------------•----------............. DATE_.50�77'-L_fl..n_aa 7--------------------------- REVIEWEDBY---------------------_- ---------------------------------------------------------------------------------------------------- DATE------------- ------------------•-•:....-:---•----------- BUILDINGPERMIT ISSUED--------------------------------------------------------------_-------------------------------------- DATE---------------------------------------- --------------- and/or recommendations:------------------ --- -- --------------------------------•---•-------•--•------------------•-•----••--------------------------------------------------------- --------------__ ------•--------------------------------------•------•--_-• _ - -------------------------------------- ------------------------------------•---------------------- ------I---------------------------•-•-----•----------------------- ----------------------------------•----•--- FINAL INSPECTION BY- l ---------- --' ----------• Date_v��/ ��/� SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 124 Sycamore Street 205 West 9th Street k Stockton,California Lodi,California _ Manteca,California Tracy,California Vr..r•+--yP- �� ES 9 REVISED 8-59 2M 5-62 ATLAS - A