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��FOR OFFICE USE: � APPLICATION FOR SANITATION PERMIT Permit No. -..___.___. [Complete in Duplicate} I --------------------------------------------------------- ----- -- } � Date Issued _ . ..... .__1.. _________.____.._._ This Permit Expires 1 Year From Date_Issued 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 maple in cam lianc it oun Ordinance No. 54 iA1r= r &-H io tua "O 55`( GA/- ,et + 1ik). l93w3�0_C17 JOB ADDRESS AN LOCATION.__ _ �`'t�•?�� ---------------•-•••••• ----------- -7 Owner's Name _La. . I -�Q--•------------------ honed... �Q .Q.� Address..................•...... .,... i ----- ------------•-------....---- ------ ---------•••--....•-••----------•- Contractor's Name..�1_, .�.- Phone-�?.Tom.-..� I Installation will serve: Residence partm t House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: J____ Number of bedrooms ._Number of aths __/___ Lot size ......1_e2. _ .. _ __ Water Supply: Public system [3Community system El Private Depth To ater Table ........ ft. � f Character of soil to a depth of 3 feet: Sand ❑ Grave{ ❑ Sandy Loam Clay Loam ❑ Clay ❑ Adobe❑ Hardpan ❑ f k Previous Application Made: (If yes,date____________________) No ❑ New Construction: Yes ❑ No ❑ FHA/VA: Yes ❑ . No ❑ r 9ic, F INSTALLATION AND SPECIFICATIONS:No septic tank or cesspool permitted if public sewer is available within 200 feet.) . 1 Distance from nearest well_________________Distance from foundation-_._..._...._______-Material------------------------------------------------- No. of compartments-------- -----------------Size---------------------•----------Liquid depth---•-•-•------------------Capacity----------------------- �• vmposa t I Distance from nearest well [�___Distance from foundation--_/Q__�....Distance to nearest lot Number of lines_____1_ _..._.___r__._ ._ -Length of each line------ --------Width of trench__c� `............ dType of filter material vepth of filter matenal..._...L .....Total length......_____________. .r Seepage 1 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------------------------------------- 13 Size: Diameter----------- ------Depth----:---------------------------------------------•-Liquid Capacity------------•---••--_-•----gals. Privy: Distance from nearest well------------------------------------------------- from nearest building "F ❑ Distance to nearest lot line--------------------------------------------------------------------------•--•---•---------------- -•---•--------------- -------- 6 --- •--•••----•--•-----•----•------------- Remodeling and/or repairing [describel------ ----- -- - ---- ----------- --•---------------•-•---•--•------------- ------- ----•------------- --•----.-.---•---•------------------------••---••---------------------- ----- ------------------ ---•------------y--•---•---------- - ---------------------------------...--------------- ---------------------------------------------------------------•----------- --- - ---- --- - --- ----....------•-----••-•---------------- --------------------------------- - ------•---- ----------------------------•-------------_- •---------------------------.--•--AllFbe --------------------------------.----••--•------••------- ----------------- . hereby certify that 1 have prepared this application and that the work done in accordance with San Joaquin County ordinances, State laws, and r les and regulations of the San oaquin Local Health District tract t (Signed).. w {�ccteflaoyCon ori By:----------------------------•--..Gl............. - ------(Title)--------------------------------------..._...--- ---- -------- (Plot plan, showing size of lot, Iota+ion of system in relation + wells, buildings, et ., can be placed on reverse side). FOR DEPARTMENT USE ONLY ► APPLICATION ACCEPTED BY ' --------------- DATE 6 --- ----- ------ ---------------------------- REVIEWEDBY--------•-------------•-----••-------------------------------------------------------•---------------------------------------- DATE------------.-.--------•------------- ._-.._...---------- BUILDINGPERMIT ISSUED................... ------------------------------------------------------------------------------ DATE------------------------------------------------------------- Alterations and/or recommendations:--------------------------------------------------------•-------------- ------------_-------------•-------.....---------------•------•--•---._--------------- -----------------------------••---------------------------------------------•----------------------------------•--•----------------- --------------: -----------•-----_----••----------••---••----•-•-••-----------------•--- -----------•-•------------------•--•----•T----••---......-------•--.----•-----------------------._..__.-_------- ---•-•---------------------•--•-•---- -------------•--•------------------ ------------------- ----- ---------------------------------•------------------.-•--•-•----------------------------------•-•-------------------- ------------------ - - -- - f 1r"`, ti .. } i FINAL INSPECTION BY--------- ----- ----'-- ----------------- ------------------- Date _��4�*------------------------------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT h 130 South American Street 300 West oak Srreet 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,California Manteca,California Tracy,California' E5 9 REV15ED a-59 2M 9-42 ATLAS