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FOR OFFICE USE: ------------------ %--------.--------- ------------------ -- APPLICATION FOR SANITATION PERMIT Permit No. l. 3 --------------------•----------------------------------- (Complete in Duplicate) S 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. JOB ADDRESS AND L ATION. t?_------------ Owner's Name..... ------ -- ------ .Phone---------------- Address......... ` ----------- ----------- Contractor's Name -----------------------------------.................... Phone"_............ .................... Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units:_ _ Number of bedrooms __ Number of baths _-/__ Lot size _ Water Supply: Public system 2_*'Communit system y stem ❑ Private ❑ Depth to Water Table Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe 2--(dardpan ❑ Previous Application Made: (If yes,date--------------------) No 'New Construction: Yes ❑ No Ra'_FHA/VA: Yes ❑ No ®�- TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic'tank:or cesspool permitted if public sewer is available within 200 feet.) Sppt;c Tank: } Distance.,from nearest well-----------------Distance from foundation-------------------Mater`ial-___.----------------....._...___..__......-__._. �X13r iR¢ , t No'. ofmpartments =- -= --._Size.-: ---------- Liquid depth-- - Ca aci ,. P ty....................... Dispofal Field:` 'Distance from nearest well---- ----------Disfance,from foundation_......._____.______Distance to nearest lot line................ Number of lines---------------• -------------------Length of each line_._..--------------•-••-•----.Width of trench., Type of filter material-------------------------Depth of filter material------- /.-___---_Total length.---__----_----..-------_---_--- Seepage Pit: Distance to nearest well--__:�--�------Distance f m, fo ndation_.-,f�. -._-.Dis a ce to nearest lot line-+�1'__ ... Number of pits-..._/-------------Lining material--YV Size: Diameter_aUe---•------_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 0 --------------- -_-- -----------------••-- Remodeling and/or repairing (describe):--.--_--______ ___ ' ------•----•_--_----.---- -•-----------------••------•-- -----------•----------•--------------•-------•---•---•-----•---•--------------••------- --•------------------------ = ...:_= ------------•--------------•-•-------- ------ I hereby certify that I have prepared this application and-that the work will be done in accordance with San Joaquin County ordinances, State laws, and rules and regulations o the San Joaquin Local Health District. I (Signed}_ (8wner-end�os Contractor) ----------••------------ - - -- ----- By:__.... -----------•- •--------------- -- ---- (Title) at plan, showing size of lot, location of system i ' ation to wells, buildings, etc., can be placed on reverse side). I FOR EPARTMENT USE ONLY APPLICATION ACCEPTED BY_-__ _.- --._ ._ L l-_ -------------------- DATE__ ------------------ ! G �- - -------------------- ------------------------------ -- - -•---------------------------- REVIEWG E -----...IS -- E ---- --------------------------------------------------------------•------- -----. DATE --.----- UILDING PERMIT ISSUED__...... - --------------- ------------- DATE---------- - ------------------•- Alterations and/or recom end' ions:---------- ------ •----- ---------- •-------•----•-•------•----------•------------------------•----------- --------------------------• ------••----------- FINAL INSPECTION BY:....... ... Date------ 2 AN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street' f 124 Sycamore Streit%' 205 West 9th Street Stockton,California Lod],California Manteca,California ._� Tracy,California 96 9 REVISED B-59 2M 5-61 ATLAS - � -