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FOR OFFIC ---- APPLICATION FOR SANITATION PERMIT Permit No. -f-•--._ ------------------------ ------------------------------ (Complete in Duplicate) Date Issued --------------.------------.__.------------------..-- is Permit Expires 1 Year From Date Issue 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 AND LOCATION----. . .:®-. .. -.�....CQ ..............................................---..�...A.. ............ . Owner's Name--------- --- - -- ..... .... ---------------------------------------------------------------•------ Address.... ----Address............... .`....... ...------....--.--.::.{y__..........._.--...._......_.-.----r-.__------..-.___ ____..____..__._----....._--. -..._........._____..____.____..__._ c.... Contractor's Name------�- --•--...- - -•--.. �� ..--- -- �-``�- -------...----•............... Phone-A----- ._...---�-/-- ; Installation will serve: Residence �Apartment House ❑ Commercial 0 Trailer Court ❑ Motel ❑ Other ❑ d Number of living units: Number of bedrooms .,__ Number of baths __-Z_ Lot size ...... _ --.- -1 _b........:................ Water Supply: Public system a Community system ❑ Private ❑ Depth to Water Tablez_. ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ AdobeHardpan ❑ Previous Application Made: (If yes,date--------------------) .No D�r- New Construction: Yes E3"No ❑ FHA/VA: Yes ❑ No 11 f TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) S. tic T k: Distance from nearest well-------- -.:Distance from foundation-------------------Material--------------------.--................... ....... No. of compartments--------------------------Size-------------------------------.Liquid depth--------------------------Capacity-_--_-----...------ pisposa Qld: Distance from nearest well_- -Distance from foundation-_•.t�__-..----Distance to nearest lot line._�.�...... Number of li,nes-.........I--------------------------Length of each line......... 16-.t 4---------Width of trench.}-.-Z_1---------------------- Type of filter material._.__--. Depth of filter material-------It_---,__-_-Total length......... ............................. 0 a Seepage Pit: Distance to nearest well--_ Q::_ .Diistance from foundation...._0 -1-__-...Distance to nearest lot dine__--J-----,-.- [v� Number of pits--------t------------Lining material-_.R-k-_<_ .-----Size: Diameter-- --- -- --- - - --------Depth__ Cesspool: Distance from nearest well................Distance from foundation--"-' - _----.- - ---� E_ining material-.----.-.-..-------------__----_----- r , ❑ Size: Diameter--------------------------------------Depth---------------------f-----------------------------Liquid Capacity--------------------.------gals. `V Privy: Distance from nearest well-----------------------------------------Y--_-.-Distance from nearest building------------_--_-__--.-__............. ❑ -------- -_..... Distanceto nearest lot line-----------------------�--�--- - --- ---- ------------------•-•------•,•,-•-•-•-•-------•=--•-------•------------•-••-----•-----...-.._-. Rem deIing and/or repairing� scribe :------ r .' .......0.-4--------• •---- -------- --••- ............. ' 4• "' j" - (�- --- --------------------------------------------------- ------------------------------------------------------------ ---=--- -------•-••--..�..-- -- ----------•----- U -------------•---------------------------------,--- ---•-----•-------------------------------------------------------------•-------- -•------------------•----------------....---------------------------------- ---------------- - -------------------------------------------------•------------------- = hereby certify that I have prepared this application and that the work wilC be done in accordance with San Joaquin County 2 ordinances, State laws, and rules and regulations of the San Joaquin Local�H�ea_lth District. (Signed. r- l� ------ f _ vim ----------------- :(Owner and/or Contractor) a • f -Sti.r ------------- ----------------------------------- ...................(Title)..... ? Y' (Plot plan, showing size f lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY . ---------------------------------- DATE--- -------------------- � REVIEWEDBY-----------------------i-------------------- -------------------------------------------------------------------------------- DATE...-- ..-..--------• ---- ----• - -- .......... BUILDING PERMIT ISSUED--':!:-------------- -------- ---------------- DATE. ------------------------------------ Alterations and/or recommend'ations:---��_.� ---d' ..- ;.rflK--- litY .... /_ ---w- iY---------------------------------- - FINAL INSPECTION BY:.�— ...... ----- ------------ Date--- = --------/. --'--� �� . �r SAN JOAQUIN LOCAL HEALTH,ISTRI T 730 South American Street 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,California Manteca,California Tracy,California ED 9 REVISED S-89 2M 6-81 ATLAS . - 9