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F R OFFICE USE: ------------------ ------ -- APPLICATION FOR SANITATION PERMIT Permit No. ..4..a-. ------------------------- ---- ------------------------------------------------ -- (Complete in Duplicate) .---.-.- Date Issued __._._... .1... _r�- 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. This application is made in compliance with County Ordinance No. 549. 77"1JOB ADDRESS AND CATION.-- ,/ l-C� -� .-------••--•-•-•-•-•------------------- Owner's Name--- - ------ _. _ .. -- .. Phon _________�z'*4..__7� --- Address--...........................--- 1-{J► ... ` (.......... ----------------------------------------------- •- -.... Contractor's Name---- ----- ------- ------............................ Phon -•-_�-• •------------ ----.... Installation will serve: Residence Ug-� Ap rtment /House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ T Number of living units: _____ N ber of bedrooms Number of baths ./___ Lot size ........ -._o_' Water Supply: Public system Community system ❑ Private ❑ Depth to Water Table -------- ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe 23-1:Tardpan ❑ Previous Application Made: (If yes,date----_---------------) No ❑ New Construction: Yes ❑ No ❑ FHA/VA: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: o septic tank or cesspool permitted if public sewer is available within 200 feet.) S T Distance from nearest well-----------------Distance from foundation--------------------Material__._____..-.....,____............ .--------------- i No. of compartments------- -----------------Size---------------------------:---Liquid depth--------------------------Capacity....................... e�ll tlaeFri"Id: Distance from nearest weIL> &U-0--0istance from foundation---Jl�.........Distance to nearest lot line_............... Number of lines______ ___ ___ _________ __-____Length of each line__+ "" Tz9__f____...Width of trench-s�_.�.`!________------ �, Type of filter materials _r_ __-__Depth of filter material------I '!----Total length.......... ............... 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. _ I Privy: Distance from nearest well______________________________________.---------Distance from nearest building-------------------.____._.___-.....___-_. ❑ Distance to nearest lot line-----------------------------------------------------------------.....--------------------------.------------------------------------------- Remodeling and/or repairing (describe):.-------- -------------- ------------- --- -------------------- ----------------------------------------------------=•--- - ----- - ------ ------ ------------ - - - --------- -�__.-- ---------------- I hereby certify that I have prepared is application an that the work wi 1 be done in accordance with San Joaquin County ordinances, State la , and rules and regulations of the San Joaquin Lo Health District. (Signed)----•••/ILA---- Qy- � ` -►s-1------��- -----i L Contractor) 1 By:............................------------------------------------- ------------- - ....- . (rifle))------------------------------------------------ ------------ (Plot plan, showing size of lot, location of system in relati to wells, buildings etc., can be placed on reverse side]. ti OR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY--------- DATE REVIEWED BY--••---------------------------------- - ---- --------------------------------------------------------1. DATE BUILDINGPERMIT ISSUED------------------------------------------------------------------------------------- --•------------ DATE------------------------------------------------------------- Alterationsand/or recommendations:...------------ ------------------------------ -------------------------------------r---------------------------------------------------------------------------- -•--------------.........----------------------------------------------- --------------------•---------------------------------------------•----- ------------..-------•-•------•-•---------------------------------------- ----------------�'-`• ......... ------ ------------------- -•---• - -- -------------------- ------------------------------------------.._-. -------------•-- . -_- ------------------ FINAL INSPECTION BY: ----• Date------------- .. ---------------------------------------- V SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,California Manteca,California Tracy,California ES 9 REVISED 6.99 2M 5-61 ATLAS