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FOR OFFICE USE , tri ...................................................... APPLICATION FOR SANITATION PERMIT Permit No. . ------------ ------- --------------------- -------- (Complete in Duplicate) o/ ---------------------------------- ------------------ --- This Permit Expires 1 Year From Date Issued Date Issued -.-_. _...�lo 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 A LOCATION------....:!(_1`....../4zl....----"_411A1� j�sl...° f�"�`� ........................... Owner's Name -- Phone.................................... Address.............. ......... ................................� 3Contractor's Name... ------. SoN q.e sTPhone � Installation will serve: Residence ($) Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: ..�... Number of bedrooms`s_-- Number of baths _i�K. Lot size .....Ids..._ _ s'................ Water Supply: Public system ❑ Community system ❑ Private W Depth To 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____________________) NoX New Construction: Yes ❑ NoX 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__J_4 ...Distance from foundation....®__.Mateal-.P> ' o/VC.f- No. of compartments--------=Z-------.....Size..lo:?_0?�---0/_04-.-Liquid depth---_,6J.."_4_'................Capacity... L Disposal Field: Distance from nearest well----- _Dista ce4from foundation...✓r.�'.........Distance to nearest lot line-,/.'/y../V./• Number of lines.....-_----....__.-------Length of eachline__✓`�l�;f'E 8 Width of trench..- _tri`!................ Type of filter material... ...! its- -._Depth of filter material...cR_-G--------Total length-:-.•x.3.!1......................� Seepage Pit: Distance to nearest well----------------------Distance from foundation....................Distance to nearest lot line--------. ------ ❑ Number of pits......................Lining material--------------_-__.___Size: Diameter-............--------- Depth...............................1006 Cesspool: Distance from nearest well.................Distance from foundation--------------------Lining material..................................... +� ❑ Size: Diameter-------------------------------------Depth------ -------------------------- ------------------Liquid Capacity............................ Privy: Distance from nearest well.................................................Distance from nearest building..-.....----_--------------------------... ' ❑ Distance to nearest lot line--c4'----------------- -•--------•------------------ ---------------------------------------------------------------------------------------------- Remodeling and/or repairing (describe):---------A__/ '01 y�X.............G7.4--7X-----... -•------------------•-----•••---•-------•-----•--•--•--- --------•---------------------------------------------•-------•----•------•------•--------------------•--•---••---------•-•-----•---•------------•----•---•--•---------------•----•--.---•---••---....----•-•............... --------------------------•-----------•-------------•------••--•--------•--------------------------------------------•---------------------------------------------.................................................... ------------------------------------ ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ 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. (Signed)--------- --- _ - - --- ------------------ -`--.A A�-D,�_ -�--------- ------(Owner and/or Contractor) --_. ----------------------------------------------------------(Title)__0_0-------- (Plot plan, showing size of lot,-locatio of system in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATIONACCEPTED BY-------------------------------------------------------------------------------------------------- DATE........................................................... REVIEWEDBY------------------------------------------------------------------------------------------------------------------------------ DATE----- . -- -- . ---•-------•---------------•--- BUILDING PERMIT ISSUED --- ------------------ ------ DATE.. .. f �------------------------. ------------- Alterations and/or recommendations------------------------------- 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 ES 9 REVISED a-59 2M 5-62 ATLAS