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FOR OFFICE USS: ---------- ------- APPLICATION FOR SANITATION PERMIT Permit Nq. .......... -------------- MV - ---------- ---------q-tk ----------------------- (Complete in Duplicate) ------------- ------------- This Permit Expires I Year From Date Issued Date Issued .... Application is hereby made to the San Joaquin Local Health District for a permit to construct and inst the work herein described. This application is made in compliance with County 05inanc e, . 549. JOB ADDRESS AND LO��TION_ --------------7----------- ---------------------- --- Owner's .... . .... .. .. Name...... .................... ------------------------------------------------------------------- Phone -- --------------------------------- Address................... Cont4ctor's Name__,_;;i�_ �.,�-kpartment J� ... ........ --- -----S4 _C .X4 ......................................... Phone..4. .j Installation will serve: Reside 'House [] Commercial ❑ Trailer Court E] Motel [I Other El Number of living units: Number of bedrooms -2---Number of baths/... Lot size :.....1___2—.-..0........ Water Supply: Public system Community system E] Private [:] Depth to Water Table & ft. Character of soil to a depth of 3 feet: Sand[] Gravel E] Sandy Loam E] Clay Loam [3 Clay [] Adobe� Hardpan 0 Previous Application Made: (If yes,date------ -------------) No 0 New Construction: Yes El N FHA/VA: Yes E] No TYPE OF INSTALLATION AND SPECIFICATIONS: OX No septic tank or cesspool permitted if public sewer is available within 200 feet.) S Distance from nearest well_________________Distance from foundation....................Material.................................... No!-of compartments-------------------------Size................................Liquid depth....--------------------- Capacity........ Distance from nearest well.A_01--..Distance from foundation-__L O.........Distance to nearest lot I' e..___:......... Nu' ber of lines..... Z -----Length of each line'�tZ_9)----I!------------Width of trench. Type of filter me- -------Depth of filter material ....Total length-------------- t�%a .._�f ks Seepage Pit: Distance to nearest we11_04.rLJ9-___Distance ifrq9L foundation_ -D-./___.Distance to nearest lot line.. Number of pits__: ----------------Lin ihg'kmaterial.0!�_.e_��A....Size: Diameter---v30.*/...Depth------ ............... Cesspool: Distance from nearest well____-__-f----�:._Djstance from foundation' F_;-----:---------Lining material.............................. El Size: Diameter--- S" ---------------------........... De'pth--- -----------------Liquid Capacity.....................f=.gal Privy: Distance frbm nearest well...------------------------------ !--------Distance from nearest building------------------------- ❑ Distance to, nearest lot line------------- -------------------------------------------- Remodeling and/or repairing (describe):----- ---_------------------- --------- ---------------=--.............................I......... . .......... -----------*----------------- I............................................................................. ......... _;-- ---------------------- ------- -------------------------------- -- ---- - ---------- . ."---1-1-7............. --------------------------------------------------------------------------------------- ------....... --- -------------- .. .... ........... .... ........... ------------------------------------------------------------------------------------------------------------------------------------------------------ ............................................... .....-----------`--i *N o Distance pid- Distance N Tyr ,.....+__._ ... I hereby certify that I have prepared this application and that the work. 11-be done in accordance with San Joaquin County I ordinances,_§t4e4eWs, "drules and regulations of_thq.Spn J quire,Loa-al'ijpalth District. (Signed) .................... ....... _ - ---------- .. .... ------------------------------------------- Contractor) By:................................................................................ -----------------(Title)------ ----------------(Title)------ ------------------------- ---- - ---------- -- --------------- (Plot plan, showing size, of lot, location of system in re on to wells; build' s,etc:, reverseFairi-bePli-ced-6—ni e). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY/ ------------------------- DATE--------) .. ......... REVIEWEDBY-------------------------- - ---------- ------------------------- ------------------------------------------- -------- DATE................................. ............................ BUILDING PERMIT ISSUED_- _.-------------------------------- ........... -----------------------*--------------------------- ........... DATE------....... 1 4 T .......... . .....P.�i..... Alterations and/or recommendations:_._ — ._____- ..................C .... .. -------------------- ----------------------------------------------------------------------------------------------------------------------------------------------- ..........-------------------•-----•----•--- ------------------------------------------------------------------------------------------------------------------------------------------------------------",----------------- ............-----------------------------------------------------I------------------------------------------------------------------------- .................. -------------------------------------------I..............I.......... --------------- .......... n�t----------------------------*-------------------------------- ---------------- ......................... --------------- ------------------------------------------------------------ FINAL INSPECTION BY:-_._ ..y....... ............................. Date...... X A-k . ......... ---------------------------------- .6;1 1.11 SAN JOAQUIN LOCAL HEALTHkj DISTRICT 130 South American Street 300 West Oak Sireet 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,California Manteca,California Tracy,California ES 9 REVISED 5-59 21A 5-61 ATLAS