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FOR OFFICE USE: `W ------------------------------------ ------------- APPLICATION FOR SANITATION PERMIT Permit No. .-- "�� ------------------------------------------------------- (Complete in Duplicate) 3 ---------------------------------------------- ---- - This Permit Expires 1 Year From Date Issued Date Issued .._.. ��.J 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 LOCATION. . ._/w ............... Owner's Name--------- .. -- • - -------- r ------------------------------------------------------------- --•--- •--•------ Phone------------------------------- �jAddress---...... d 1 !' --, A•.•�--•-• �- Contractor's Name_ 'Y----------------•----•••---- --- ••.... Phone----------------------------------- Installation will serve: Residence M Apartment House ❑ Commercial ❑ Trailer Court I] Motel ❑ Other ❑ Number of living units: _lf..... Number of bedrooms __'I___ Number of baths __-__ Lot size _..;—0_ •_._.......I................. Water Supply: Public system ❑ Community system ❑ Private N Depth To Water Table XR_. it. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam [] Clay ❑ Adobe ❑ Hardpan]a] 1.. a9 Previous Application Made: (If yes,date-_._______________) No New Construction: Yes ] No ElFHA/VA: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) ww Septic Tank: Distance from nearest well.a70�--------Distance fromjferial.:4_�_. __ �............I---------- ;iJ No. of compartments.---_An----------------- t Z-}--44--_-Liquid depth.......$"---------------Capacity_/47-0.0........ Disposal Field: Distance from nearest well.XP....._.._Distance from foundation.__---w'-`Distance-to nearest lot line.rr.......... Number of lines---- ----------Length of each line----- _P7R:--------------Width of ti ________________ j Type of filter materi -----Depth offilter 'material___. -----------Total length___ _U"P'.......................... Seepage Pit: Distance to nearest well--.ems' r � ' _ _______.D�stance from foundation..:14?....._.__-.pistance to nearest lot iine.__,�..._..._.. Lb Number of pits-A---------------Lining material__--__.Size: Diameter._._�e'4..:'_........Depth-_-_d7_.r---.__.._______-__---- k� Cesspool: Distance from nearest well-----------------Distance from-foundation--------------------Lining material__-__-_..__._----______.------------- _ ❑ Size: Diameter--------------------------- ----------Depth------------------------- •- -- ---------___Li quid Capacity•------•----••--------------gals. Privy: Distance from nearest well--------------------------------------- ---.Distance from nearest building____-_.______________________-.._--------- ❑ Distance to nearest lot line------------••---------•---------------------------------------------------------•---------•-----•-----------•-------------------------------- } Remodeling and/or repairing (describe):---------------------------••------------------•-•-•---•-=----•--••----------••----------------•---•----------------•-----------•_--------•------------- --•--•----------••---•---.---•-•--------------------•------------------------•------------------------------------------=---------------=---------------•------ -•---•------------•----------•--•---------•-- - =� ,a s s 1 I hereby certify that I have prepared this application and +hat the work will be done in accordance with San Joaquin County ordinances, State laws, andrules d regulations of the San Joaquin Local Health District. d (Signed)_� ...... ._.. - w - ----------------------=----------------------------------•---------------•---(Owner and/or Contractor) By:--------------------------------------------------------- -•.._ ..--••-•--== - •--' •----(Title)------------------------------ ------_........ --- -- .-.-- (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�!'r ____-._-- --.--_-__-- DATE--- --`�.3-"�- -.._ ._ ._ -------------------------- ----------------- REVIEWEDBY--------------------------------------------- ----------------------------------------------------------=------------------•- DATE------ ------------....------------------------------------ BUILDINGPERMIT ISSUED----------------------------------------------------------------------------------------------------- DATE------------------- --------------------------------- Alterations and/or recommendations:------ -•----- --- -------------------------- -------------------------------..............................................-------------------------.......... ---------------------------•------------------- ------ f �. — - r 101) ._ ' -- ter^ --•�� ........... ... --------------------------------------------- -------- .-------------- ---------------- -------- ----- -------- - -- --------------------------------------------------------------------------------------------------------------------------------------------------- lv----------------- t FINAL INSPECTION BY:---------- Date--------------------- ---------------------------------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 124 sycamore Street 205 West 9th Street t Stockton,California Lodi,California Manteca,California Tracy,California ES 9 REVISED 8-59 2M 5-62 ATLAS _ I . t