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FOR OFFICE USE., i I ---------------------------------------------------- -- APPLICATION FOR SANITATION PERMIT Permit No. :. ............ _._ {Complete in Duplicate) ��/mooA63 ------------------ ----------------------------- 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. i This application is made in compliance with County Ordinance No. 549. JOB ADDRESS AND LOCATION . ��:6.3 -- -------------------------------------------------- Owner's Name---•---------_-- -• . ---------------- ------------ Phone........-•-----------_------- .. Address.- -- s�..�.13 --------------------------------------------------- .7 •- Contractor's Name---------------_- ----••----•,--------•------ Phone.......-------•-----••--•-••------- - fes- 1• •- - -- ------------#-------••--._._....------••-------------....--- � • - - e Installation will serve: Residence 0 -Apartment House,❑ Commercial ❑ Trailer Cor ❑ Motel ❑ Other ❑ Number of living units: ---------Number of bedroom��-_. Number of baths _�-___ Lot size ------------•---••-•-•-••------- Water Supply: Public system a Community system ❑ Private ❑ Depth to Water Table -------- ft. Character of soil to a depth of 3 f et'�°`�Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam Q Clay ❑ Adobe Hardpan ❑ r It Previous Application Made: (If yes,date____________________) No {A New Construction: Yes ['No ❑ FHA/VA. Yes ❑ IS ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: jr No se tic tank or cesspool permitted if public sew er is available within 200 feet.) Septic Tank: Distance from nearest well------ ____rDistance from foundation.____l. ____.._.Material............. ... ........................... No. of compartments ' eSize---- -- q p R ( Capacity 47 Disposal _ ield: Distance from nearest well_ s-D__'Dr istance from foundation..-/-C7.... .Qistanca to nearest lot line............ encr Number of lines----------------1--------------S'�_Length of each line----------�-O--------f--Width of th.---- -----�..-------•------- Type of filter material.,Q4,6_z epth of filter material____.__`___Q-- -!-Total length._.__.------` ..____.___.-_J.. Seepage i = Distance to nearest well___//. _a_0__._____Uistance from foundation..._f.C� ..'Distance to nearest lot line----CJ.....___-_ u" - Number of pits...-t____�--_----..Lining material__ ,�z .5ize: Diameter____3-----------------Depth-___--.�. _._.:.------..... ss ool: Distance from ne1k IV arest well________________Distant trom foundation----------- material__.___--___.__.-___-------____.....- Ce p - ❑ Size: Diameter--- Depth ----------------!- Liquid Capacity--------------------.-------gals. Privy: Distance from nearest well----------------- -----------•--=----------�Di stance Ifrom-nearest building______._..-____•-••--•-----••------ Vr ❑ i .-•--- Dlstance to nearest of line----------------Y----------------------------- --------------•-•---------------------_:....------• _.---------•-------•------------- --•-- ------------••-•--.---•-------• J� Remodeling and/or repairing (describre)--------------------------- ------------- ...................-------------......------_----•--- ------- - 1 I ---------------------------••----------=--------------••---•--------------••---------- ------- i ----••---------•----••----------••---•-•-----------------------------••------• ------------ •- -------- --------------— ----------------- -----------------• ----------- .--•-------------.- -•----. ------------ ------------------------------------------•--- ------------------------------------------------ ---------- ! ...---------..------------------------------ -•---•--•-•------------------------------ � I I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County `6r21irtances, State laws, and rules and regulations of the an Joaquin Local Health District. ) (Signod ------•-------- -----------------------------(Owner and/or Contractor SY= {T'itle) ---------------------------------------•---------------ion-- --------•--------------•------- (Plot plan. showing size of lot, location of system in relatif n to we11s, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY ' --- F APPLICATION ACCEPTED BY '� QATE_: ._`_IY-JD - ... - ------------ - --- t "` `..-:----. .. DATE-_---•-----------------• ---•---------- REVIEWED BY........*._ -------- ------------------------- - ---- ----------- IDATE ------------- ------ BUILDING PERMIT ISSUED--------------I- Alterations and/or recommendations:.--____-_ D ..-._--__,� -2- _ __. �.. .._,___.. - - -- --- ---- ----- - -------------- FINALINSPECTION BY:..-.--.---------------- ------------------- Date-------------------------------------------------------------------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Sfroot 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,California Manteca,California Tracy,California Ea'0 REVISED B•59 ZM 5-61 ATLAS