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FOR OFFICE USE: la: ' r _ ��__- /'Ji_/. -2________________ APPLICATION FOR SANITATION PERMIT Permit No. ....�..:��.;�- ------------------ ------------- (Complete in Duplicate)zc�L Z /(0 i_ This Permit Expires 1 Year From Date Issued Date Issued ...::.,...c.. '. 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 C�ounN Ordiance.No. 549. JOB ADDRESS AND LOCATION.... , c ,,.�,ce. � - -_ ti .�C1� tC. /' °3 7 - 7 Owners Name--"--t `�_._:"�c --...-- � �=C'-=-f "-"""-"---"------------------------ ------------------------- ----------------- Phon ...................................... Address..... .. .. .... .. �_:' . .:... ti L L ------ .._........ ...... Contractor's Name _ � .. t __•--•.................•-•------.-•-- Phone................................... -------------- ---"-••------.-----------•.."-------------------- f Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: __1.... Number of bedrooms Number of baths -----1. Lot size .....4.'.. _`.,Y...t.. ...................... Water Supply: Public system t Community system ❑ Private ❑ Depth to Water Table 4_S_ ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam❑ Clay Loam ❑ Clay❑ AdobwS Hardpan ❑ Previous Application Made: (if yes,date-----------_--------) No R 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 Tank: Distance from nearest well..-.Distance from foundation..._t.f'.........Material"._ ® No. of compartments----------- Size.....q._X__ ._X.5._..Liquid depth.......... ............capacity....Dza ld.p , Disposal Field: Distance from nearest welL__w_- ' Distance from foundation.._Z .. .f' istance to nearest lot line""...5..... ® Number of lines...........3---------------------Length of each..line.._. Q , x_OYJWidth of french.._._..4_!!.................. Type of filter material._jjr_C_.K._______Depth of filter material..t_1."_-_____-__Total length..... f.?_'....................... Seepage Pit: Distance to nearest well __...Distance from foundation..................".Distance t nearest lot line................. ❑ Number f pits.......................lin ng ma erial.-------•-----••---•---Size: Diameter---------------•--••......................I, Cesspool: Distance from nearest well.................Distance from foundation....................Lining material..............__.................... W ❑ Size: Diameter--------------------------------------Depth----------------------------------------------------Liquid Capacity.............................gals. Privy: Distance from nearest well-----------------------------------------_-------Distance from nearest building...............I.......................... ❑ Distance to nearest lot line-------------------------------- .......................... --------------•-••------ •--------•--..._----•------•. Remodeling and/or repairing (describe):------------------------------------------�- ---• _.. "--------------------"- - •----"••---"...--••----•v= 13 • .---- ...............................................-................................................................................................................... p ..............................................".........3--...___...._---------•---•----•--•-•------_•------"-------------••---•----•-----•--------•--------•-•-----•-••------."--••----_-•"--_---•-_----•--•-----•-----•-__-_ I hereby certify that:] have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State and rules and regulations of the San Joaquin Local Health District. (Signed)_---)'�•----•-- �h °` .........V1. -- ---:------------------------------------------------------•-------------------(Owner end(or Contractor) 6 • •--•--••---•......-•--••(Title)-------------------------------------- .� (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY....t `-- --"-----"- ---•--•------••---•---•- DATE---- `"fc. ................... REVIEWEDBY...................................... / ...-----------------------------•-----------------------•......-----•--•--..... DATE............................................................ BUILDINGPERMIT ISSUED--------------------------------------------"-------------"--"--------------------------_--------._ DATE............................................................ Alterations and/or recd mendation . , __ _. _______________ ----------- `rp.-. ..Z........... . r- _. .. _ ............. -------------- ... ------------------ -----------------------------.--- '�• "' • t^ 1. r ..... FINAL INSPECTION BY:... ---- Date----------- .--"-- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,California Manteca,California Tracy,California El 0 REVISED 8-59 2M 6-61 ATLAS