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FOR OFFICE USE: ----------------------------------------- APPLICATION FOR SANITATION PERMIT Permit No. ... �l..a. (Complete in Duplicate} _ -------------------- This Permit Expires 1 Year From Date Issued 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 AN LpCATION. ___._._._�_a 1 i 1 x Owner's Name__.___ _ •••-- --------------------------- Address------ - --- --•---- ---------------------- . Phone---------- ----------- ------- Contractor's Name______________ --- -----------•---------•------------------------------------- -- Installation will serve: Residence lyrment House ❑ Commercial y� ❑ Trailer Court ❑ Motel [I Other ❑ Number of living units: _/____ Number of bedrooms .__Number of baths _J_... Lot size ....... Water Supply. Publics stem ................'------ - y ❑ Community system ❑ Private � Depth ro Water Table �.- ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam [J Clay Loam ❑ Clay ❑ Adobe[ Hardpan ❑ Previous Application Made: (If yes,date--------------------) No JZ�,_ New Construction: Yes r No FHA/VA: Yes ❑ No� TYPE OF INSTALLATION AND SPECIFICATIONS: (No. septic tank_or cesspooh.permiffed if.public.sewer.is available within 200feet. -. 4Diso�sal Ta Distance from nearest well-----------------Distance from foundation-----..___--____--.Material .__________.___._•-_- ---• --��_ �� No. of compartments Size_. .-Liquid depth--------------------------capacity----------------- Field: Distance from nearest well _.._Distance from foundation_____ __ ----Distance to nearest lot line..__,•__...._. �• ` r Number of lines----f__________________________ _Len th of each fine_.. �__ ,ST v` g �- Width of trench. rZ•_�'_-----,- Type of filter material.- '�� " Depth of filter material____ -Q Total length___ --- p eepage 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------------------- Linin material-------.-...-----------••----- - •- ❑ Size: Diameter -----------------_-- ------Depth-----------------------------------------------------Li uid Ca aci .•-- �- --�- -._.�. -.� _ �. ._ _. q p •----------••---------------gals. Priv . - -.; x. - - 4_--_..:. _,' - Y' Distance from nearest well__________________________ Y '"""�'• - ` - ' - -----------------------Distance from nearest building` g Distance to nearest lot line_________________________ - ----------------------- Remodeling and/or repairing (describe)----------------------------•------- 1 --..--•----•---------------•-----•-----------------------•----------•--------------------------------•--•--•---- •---•------------------------------------ -----------•-----• -------•---------------------•----------------•-=----------------------------•--•---------------------------•------------•----------------------------------- I hereby certify that Il have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State laws, an �rule:s and regulations of the San Joaquin Local Health District. (Signed)- .�.�- 8y:__... - n e r an r Contract - (Tiffs} ------------- ------ - o tractor) (Plot plan,'shoLF,ng size of lot,-locefion"of system in relation to wells, buildings, etc., can be placed r^o rno everse sids \ � k �....r �- FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY----------------------------------- DATE REVIEWED BY.---- - --- --------•---••----- -=•-----•-------- -------------------•---------=- ------------------------•------------- -- =--•------- DATE.-----/-- . . ..-•------- BUILDING PERMIT ISSUED.-----•-------••----------------------------------- ,�-�---a--�--�}- _ . DATE- ------------------ `/ Alterations and/or recommendations---------__.___._.._---_--.--_ --------------------------------------------------------- FINAL INSPECTION BY: ------------ -------- GY_ Date SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street - ]24 Sycamore Street 305 West 9th Street Stockton,Colifornla Lodi,California Manteca,California E5 9 REVISED 8.59 2M 5-62 ATLAS Tray,Californfd