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FOR O�CE US'E .5 ______________'___._____..___'._f-_ ___._________. APPLICATION FOR SANITATION PERMIT Permit No. _.. . --------------- ' (Complete in Duplicate ----------- -- --------------------- This Permit Ex ires 1 Year From Date Issued Date Issued .___ .____._.___�3� 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 Coup rdc o.1 49� JOB ADDRESS AND LOCATIO =. ✓ Owner's Na?me--4° . _ `-----' s �w-n- ---•--- Phone------------------ .......... Address------ 3-� Contractor's Name------------ ........... ----• --•-------------------- Phone-----•--------- -------------------•-----•----•� •-------------------- ------------------------------------ Installation will serve: Residence Apar+ment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ i Number of living units: __, __ Number of bedrooms ^ ___- Number of baths -Q.... Lot size ............................. Water Supply: Public system P-1Communify 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 [ New Construction: Yes Z?- o El.. FHA/VA: Yes 2�- f�o ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic rik: Distance from nearest well__ ,f_-•Distance fr m foundation-10-_f__.------- Material� _.................... No. of compartments-----�______________Size____f�.��_.Liquid ..__________capacity..l�Y.._-- i .. Disposal Field: .. Distance from nearest well__""--------.Distance from foundation.fd! ------- ---Distance'to nearest lot line................. Number of lines____ [J)� -. -4._-----------Length of each fine____ __�'�n�°E:w-lMidth of trench.:_��_�: � .. .-.------- Type of filter material.___��___.____Depth of filter material-/j `'______:___.Total length____�.,��?........_------________ Seepage Pit: Distance to nearest well----------------------Distance from foundation----.------------.__.Distance to nearest lot line____________._.._ © Number of pits----------------------Lining material-----------------------Size: Diameter------------------------Depth-----------_-----.------------ \l Cesspool: Distance from nearest well----------------- from foundation--------------------Lining material ____--_____________________---*..... R' + ElSize: Diameter--------------------------------------Depth.-•------------------------------------------------Liquid Capacity--------------------------_.gals. Privy: Distance from nearest well-----------------------------------------____....Distance from nearest building-----------------------:.•_______..____._. ❑ Distance to nearest lot line----- ------••----------------------------------•----•-••--•------••-----•------...:.- Remodelingand/or repairing (describe):------- ------ ---------------------------••--------------------------_....._•------••-----•-----------••-------•--._....------...._.------------------- •-------------------••----••--- •---------•----------•---•-•-----------------------------....._-------------------------------------------•-•----------------•----------------------------.---------------------------------- ---------------------•-•--------------------•------------------------------- ----------------------------------------------••------••--------------•----------•-----------------•----------------------------------- I hereby certify that I have prepared this ap- lication and that the work will be done in accordance with San Joaquin County ordinances, State laws, and rules and re tion of the San Joaquin Local Health District. (Signed) -------- ------- ------ ------------------------------------------------------------- •------- -------[Owner and/or Contractor) i. . BY:----_---------------- - Title --------- --------------- (Plot plan, showing size of lot, locate of system in,relation to wells, buildings, etc., can be placed on reverse side). i FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY-----C--A �------------ ----- - ------ ---�----.....-•--------•---------•--- •-� ••- � ------------- �� REVIEWEDBY--------------------------------------------- --------------- ----------------- -----------------------------------------.... DATE.-_.----••--•------------------- BUILDINGPERMIT ISSUED---------------------------------------------------------------------------------------------------- DATE.------------------------------•------... Alterations and/or recommendations-------------------------------------------------------•-••------------------------•------------------•--•-------- ----------------------------------- ........ FINAL INSPECTION BY:----- ------------------------•----- Date----ate- �. .��.'.!9�-� --------------------•------------•-- - SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 Wear Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,California Manteca,California Tracy,California ES 0 REVISED B-59 2M 5-62 ATLAS