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FOR OFFICE USE: •-- ------ " APPLICATION FOR SANITATION PERMIT' Permit No. ....1_.1...�L.. -------------------------------------------------------- --------------------------------------------••----- -- - (Complete in Duplicate) q ' ._-/ ---�.._,---•�� -________________ --------------------------------- This Permit Expires 1 Year From Date Issued Date Issued 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. k 7 JOB ADDRESS ANI70 TION-----• --"� .....--;--------------------- -``�-�--�--------•-------- ------ ----------------- -- - Owner's Name.. ------- - -- -------------------------------------------••---- Phone / Address-- = = -•-• -------- --.....-•-- /� Contractor's Name...... t lilt...---- � � �•��------------------------ ph( ne . ...- . Installation will serve: Residence ,R Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ . . Number of living units: __ __ Number of bedrooms , Number of baths Lot sae . --------,04,f�---- --- -----------•. -- Water Supply: Public system ❑ Community system ❑ Private;g Depth to Water Table A:Q_ ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel [-] Sandy Loam E] Clay Loam ❑ Clay ❑ Adobe gj Hardpan ❑ Previous Application Made: (If yes,date-----------------__J No ❑ New Construction: Yes ❑ No FFIA/VA: Yes ❑ No ❑ i, ;`• TYPE OF INSTALLATION AND SPECIFICATIONS: i I (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Se • jank- Distance from nearest well-----------------Distance from foundation----..._....______Material---------------.--------------------------------- � No. of compartments----- 1------------------Size---:---•------------==----- -•-Liquid depth 4 ------------Capacity....................... a `._...Distance to nearest lot line.... Disposal field: Distance from nearest well_s�t2____. -Distance from foundati n__ i l� Number of lines_________. _____._ Length of each line.... .//._.p_� .---Width of french.-__f _f .... of filter materiae-l ��Depth of filter material------r�-_ -+------Total length----•---....----•--•-- ------------------ Type Seepage Pit: Distance to nearest well----------------------Distance from foundation....................Distance to nearest lot line-----_______..... ❑ Number of pits----------------------Lining material--------.--------------Size: Diameter----------------•-------Depth--.•-----------.._-.------------- 1 Cesspool: Distance from nearest well-----------------Distance from foundation__..------------_----Lining material__-________-__---__________.__...... Size: Diameter-------------------------- -----------------------------------------------------Liquid Capacity-. •-•-•• ------gals. ❑ -----------Depth-------------�- - Privy: Distance+om'nearest well----------------------------.----------------Distance from nearest building------------.__...__._._._.___.__..______. ❑ Distance'fo nearest lot line-------- ----•------------------------------------------------•---••------------------------------------------...--------------------------- Remodeling,and/or repairing (describe):-_- - --- - - -� ---- ------ •- ------ = jF 77Fr.� --------------------••--•-- --------•-------------------------...--- ---• --------------------•--•-----------•----------••-----------•-...---------------------------.....--------•-•---------•-----•------•--------------._. I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, to laws, and rule d regulations of the San Joa uin L al Health District. - ' -.. --• - . -- ---- - - -- --- ------------------------------ - ------ wrier and/or Contractor) (Signed)--- ; By:................................... :-- , . ( -- ---- -- ---------------------------.....{Title) c = ----------------- (Plot plan, showing size of lot, location of system in relation wells, buildings, etc., can be placed on reverse side). FOR DE ARTMENT USE ONLY APPLICATION ACCEPTED BY------- ---------•------------- -- ---------------------------------------- DATE------9----Z—_-1-_ _�R7!�r—------------------ - REVIEWEDBY----------------------------------------------------------------------------------------------------------------------------- DATE---------------------------------------------------------..- BUILDINGPERMIT ISSUED----------------------------------------------------------------------------------------------------- Dr4TE------•--------------------------------------------•-------- Alterationsand/or recommendations:----•- ---------------------------------•--•------••--•-----------......------------•-•-•----------...-------------------•--------•-•-•--•----•-----.---.----- FINAL INSPECTION BY:.-- —----------------------------------- Date---1--U . %.._-. --. ----------------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 124 Sycamore Street 305 West 91h Street Stockton,California Lodi,California Manteca,California Tracy,California E6 9 REVISED 8-89 EM 6-61 ATLAS