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FOR OFFICE USE: ------------------------- ----------------•--- J r APPLICATIONFOR}SANITATION PERMIT Permit No. ___d--..... - 5 ----------- --------------------------------------------- (Complete in Duplicate) Date issued ..... ``. -------------_------_----------------------------------- 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 made in compliance with County Ordinance No. 549. JOB ADDRESS AND LO TION ..._ 119 ---- .✓ �., ,,.`.- / ----- Phone.----------•••--------------_----- Owner's Name....... --------��--�--/--------------- -- �-�-Y1-�--�• --- ---- ------ �7 Address------...../--5-----y7-- - ---------�-•-------------------•--•-----------------..._-.----------------------------------- ---........----•--------.----------•---•----- Contractor's Name-------- -----------------------------------------•-------- ------•--•-----•-•--•--------•----------- Phone-.-.-._-------------_---------- Installation will serve: Residence F3--Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: ._,E' _ Number of bedrooms Number of baths -------- Lot size ___________________________________________________________• Water Supply: Public system 8--community system ❑ Private ❑ Depth TO Water Table -------- ft. Character of soil to a depth of 3 feet: Sand E] Gravel E] Sandy Loam E] Clay Loam ElClay Adobe 0'--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 dank: Distance from nearest well_________________Distance from foundation-----------:-------Material----------------------------------------- ._.__ . No. of compartments -_..Size.- Liquid d�ejts. Capacity- ` __....Distance from foundation..... 'Distance to nearest lot ------ _--_. � Size--- Disposal FieYd: Distance from nearest well--__._ J•••---- 4�i --- Number of lines---------------- ----------. Length of each line--_----- - -- ;---.Width of trench__--....'.------.�________....... Total length--•-•- --- - S•----•--•---------- Type of filter material. . _..,� ,,/ epth of filter material.___,--------- , 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------------.__._.______------.-_.___ ❑ Size: Diameter--------------------------- ----------Depth---------------------------------------------------.Liquid Capacity----------•----------_----gals. Privy: Distance from nearest well------------------------------------------------- from nearest building-----------.----------_----------------- C1 -_________-_----- -----.❑ Distance to nearest lot line---------------------------------------------------•-- -- 1---------••-•--•-------•----•------- ----------•--•---------.. Remodeling and/or repairing (describe):__.__��. - __ }�{ ---•-• - ---- �-� ......:............. ----•--••---------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. r. 7`- (Owner wwil�r.Centreeher) a (Signed}--• ------------------------------ f -------------- -- -- - -------------- -----------------------------'--------------------------------------------tTi+le (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on.reverse side). FOR DEPARTMENT E ONLY APPLICATION ACCEPTED BY---- -------------- --- -- - ---- ----- - •---•------------ DATE- DATE-------- - --- ----- ----•------------ --------- ------- REVIEWED BY BUILDING PERMIT ISSUED--------------------- -------- - - -------- DAT - Alterations and/or recommendation ` �-D s,,-�--r 'a_, -------4`1! .. s: _..--•----------------------------•--_--•-------------------------------- -•-----------------------••--------. --- -•-•------ --------... rte , - •- FINALINSPECTION BY------- -- - --------------------------------------------------- Date----------- --------------------•--------------------------• -- ----------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Srroot 124 Sycamore Street 205 West 9th Strout Stockton,California Lodi,California Manteca,California Tracy,California E5 9 REVISED 8.59 2M 5-62 ATLAS