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FOR OFFICE USE: ! ------------ --------------- ---- - ------------- ------------------------------_.......____---_______._. APPLICATION FOR SANITATION PERMIT Permit No. _. .......-. --------- ------------------- --------- -------- -------- (Complete in Duplicate) / 6 - � Date Issued ------------- ----------- --------- -------------------- This Permit Expires i 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. This application is made in compliance with County Ordinance JOB ADDRESS AND OC TION > 1--_ A7�5e,� k ' f ^^ ✓✓�� rr Owner's Name- ------ - —01-A.---...... /Yj.L-.�-- ------ Phone../7_.LZ -------- - - Address----------•---------• fM � --------------------------------------------------------------------------------------------------------------------------------...---...-••••-•-••-•......--•- Contractor`s Name------------------10��}�_- ..... Phone----------------------------------- Insfallafion -----••- - -••----•--;--- -------------------- ---- -------- - ------- -- Installation will serve: Residence i� rfinent House ❑ Commercial ❑ Trail r Court ❑ Motel [� Other ❑ Number of living units. J---. Number of bedrooms R, Number of baths ..�_ Lot size .......... __l_ .............. Water Supply: Public system [gl-�_Community system ❑ Private ❑ Depth To Water Table l ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam Clay ❑ Adobe❑ Hardpan ❑ Previous Application Made: (If yes,date-- .__.-) No ❑ New Construction: Yes ❑ No ❑ 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_________________Distance from foundation........ Material------........._........................---_.._.. ❑ No. of compartments--------------------------Size--------------------------------Liquid depth---r---------------------Capacity---------------------- Disposal Field: Distance from nearest well-----------------Distance from foundation--------------------Distance to nearest lot line.---------------- --- ❑ Number of lines-----------------------------------Length of each. line-------------------------------Width of trench----------------------------------- 09 Type of filter material------------------------Depth of filter material------------.----------Total length______.____._--.-__.____________________-. 6 1 Seepage. Pit: Distance to nearest well----------------------Distance from foundation....................Distance to nearest lot line................. ❑ Number of pits----------------------Lining material-----------------------Size: Diameter-------------------- Depth--------------------------------- Cesspool: Distance from nearest well---- ---.._Distance from foundation--------------------Lining material------------__-__-.____--_-__-_--- ❑ Size: Diameter--------------------------------------Depth-------------------------------------------------..Liquid Capacity---------------------------.gals. Privy: Distance from nearest well----------------------------------------- -------Distance from nearest building-_-._.-..______.._-.._........ .._--._..... Distance to nearest lot line---------------------------------------------- -------- ---------- -.....--....._-------- --•-•- ---------------------- r Remodeling and/or repairing (describer---•-------- - ---------------- -------•-------------------------- F r ---------------------------------- ------ --- --- ----- ------•-----------------------------------•---------•------•-------------• -•-•-----------------------•-- •-------..... 1..... -•---------------._...------•------•-•-------•-- ----------------- I hereby certify that I have prepared this ap lication aAfthnthe work will be done in accordance with San Joaquin County ordinances Stat laws, and rules and regulatio of the San Local Health District. (Signed)-------- ---- --- - --- ---- -- --------------------------------------------------------(Owner and/or Contractor) Br------------------------------------ - -----------(rtle)---------------------------------------- --- - -- --------- (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY--------------------------------- ------------------------- ----IKI - - ..... DATE----- --•--------------- REVIEWEDBY------------------------------ ---------------------/---------------------- DATE------------------------------------------------------------ BUILDINGPERMIT ISSUED-------------------------------------------------------------—--.----------------------------------- DATE------------------------------------------------------------- Alterations and/or recommendations:,-------------------------- ----•---• -- -------------------------------------------------------------------------------•-------------------•---------- -------•----------------------------------------------------------------------------------------------------------------------------------------------------------------- --------------------------------------------------- --------------------------------------------------------------------------- -------- ----------- -----------------------------------------------------------------------------.--.----------------------------- ------------ FINALINSPECTION BY--- -------------- -- ---v -----------•- :----•----- Date------f------ ------------------------------------------------ SAN JOAQUIN LOCAL-HEALTH DISTRICT 130 South American Street 300 Wes!Oak Street 124 Sycamore Street 205 Wes!9Th Street Stockton,California Lodi,California Manteca,California Tracy,California ES 9 REVISED 8-59 2M 5-62 ATLAS