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FOR OFFICE 3 �� �f� / % 1' a --- Permit No. ........,. .. --------------- APPLICATION FOR SANITATI N PERMIT ----------------------------------------� ------------- (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 ANDCATION... Owner's Name......Ar......... ---------------------------------------- Phone.................................... Address................................. Contractor's Name... . --- +'4 ........ -- Phone -•------•--------•----------•---------•---•--------- ----- Installation will serve: Residence [Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other Number of living units: ___�___ N ber of bedrooms ... umber of baths .1..... Lot size ...-0... .__' ........................ Water Supply: Public system Community system ❑ Private ❑ Depth To Water Tablee7 ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobeardpan ❑ Previous Application Made: (If yes,date--------_-----------) NoDo-1'Iew Construction: Yes ❑ No [jr-1`IqA/VA: Yes ❑ No 6;6— TYPE 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....................... Disposal Field: Distance from nearest well_________________Distance from foundation....................Distance to nearest lot line................. ❑ Number of lines-----------------------------------Length of each line..............................Width of trench................................... Type of filter material.------------------------Depth of filter material-----------------------Total length.......................................... Seepage ' Distance to nearest well_____!!! ----------Distance from foundation._ " _. ._..Distance to nearest lot linea .� Number of pits.........------------Lining material-_�M_�_.Size: Dlameter__....8.._-..___._.Depth._...q-;).,5'.................. Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material..................................... ❑ Size: Diameter--------------------------------------Depth----------------------------------- ----------------Liquid Capacity-- •-----------------------gals. Privy: Distance from nearest well_________________________________________ _______Distance from nearest building___________..__-_-_----.-----___--__---_-. ❑ Distance to nearest lot line---------------------------------------------------------------------------------------------------------------------------------------------- Remodeling and/or repairing (describe):---------------------- ......4 .......................................................---------------------•------------------------------------------------------------------•--------•--------------.................................................... -----•---•------------•-----------------•--------------------------------------------------------•-------•------------------------------------------------------------------------------------•----------------•-------•----- I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State is and rules and ions of the San Joaquin Local Health District. (Signed) ,,,�------------------- (Owner end/ r Contractor) By: = - ---------------------------------- (rifle) - - (Plot plan, showing size of lot, c ion of system in relatells, buildings, etc., can be placed on reverse si e. FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY----- &,5��----2------------------------------------ -----•------• DATE-------- �-3 REVIEWEDBY------------------------------------ -----�------------------- ----------------------------------------------------------. DATE--------------------•-----------------------•--------------- BUILDING PE MIT ISSUED ---- DATE -- -------------- --- ANFerations d/or recommendations:____ __--- ._.___-.- =•..... .......... -•----•-••••--•- -• ........................................... ---------------- ----• ••-••--•---•... -----. e Z C�f�LZS= ..... c f L ' /4 --- "` ` �� FINAL INSPECTION BY:.. * -` ---- ------------- Date---- .................................................... SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 124 Sycamore Street 205 West 9th Streit Stockton,California Lodi,California Manteca,California Tracy,California ES 9 REVISED 8.59 2M 5-62 ATLAS