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FOR OFFICE/-USE: .�/ s ------ 4APPLICATION FOR SANITATION PERMIT Permit No. _..�.`��....._...: - ----------------------------------------------------- - -------------------------------------------------------- (Complete in Duplicate) ______ _ ___________________ I 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 LOCATION-----�- - P----- --- -`-----------•------�-------- ------------- Owner's Name....... ... -••-•--------- ---------------------------------------- Phone.,4ZA--!r1�.A-0.,9 Address-_--------------------------•-•--............--•-• -' � --------••-----� ....-----------------•-----•--•------------•----------••-------- �r Contractor's Name--------------------------------------Q---we._. -s�----------- - Phone Installation will serve: Residence g] Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: _,o_0.._. Number of bedrooms __1'__ Number of baths __e__ Lot size ------- .......------- Water Supply: Public system g Community system ❑ Private ❑ Depth To Water Table ze 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 Q New Construction: Yes ❑ No I3 FHA/VA: Yes ❑ Nod] 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----fr�n--------Distance from foundation--_/Gl--------Material.-___ ® No. of compartments----------_'2—---------Size- Liquid depth___r,,...___--------------Capacity......... rtt'�G_a Disposal Field: Distance from nearest weil___.. - Distance from foundation------- - '_---Distance to nearest lot line------ IZ Number of lines__________________�__.____.___._Length of each line_____--__ Width of trench___.____....___��_____.... �• Type of filter material._./.�r� r�(r__Depth of filter material____.�.1_X_-'..___Total length--------------- '.d..-------••----•- Seepage Pit: Distance to nearest well-----------------------Distance from foundation....................Distance to nearest lot line----------------- 0 Number of pits---------•------------Lining material---------- ------------Size: Diameter---.....---------------Depth----------.---------------------- Cesspool: Distance from nearest well--------___ ----Distance from foundation-------------------- material _-_.__________-___._____--...-._____ Size: Diameter-------:-----------------------1---Depth------------------------------ ---------------------Liquid Capacity---------_-------------_-_gals. Privy: Distance from nearest well___,-!--------------------------------------------Distance from nearest building------------------------------------------ n ,� ❑ Distance to nearest lot line- ------------------------------------------------------------•-•----------------...._----------•-----------------------•-- ----- 1JJ i ' - Remodeling and/or repa ing d+. rib - �� i _ _ " ....i �� .J._ _----- ------------ ---•--------------- ------------ ----------------- ------ -------------------- 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 regul tions of the San Joaquin Local Health District. (Owner and/or Contractor) (Signed)..__- }, By--------------------------- •----------------------------------- -------------------- �" -----------------------------------------(Title) (Plot plan, showing size of lot, location of system in relation Wwells, buildings, etc., can be placed on reverse side). F PARTMENT USE ONLY ... --------------------------------- DATE--------- . ...." 'r 'F -•----------- APPLICATION ACCEPTED BY ----------------------- REVIEWEDBY------------------------------------------------------------------ ----•----------------------------------------------------• DATE-------- •---•-----•---------------------------------------- BUILDINGPERMIT ISSUED--------------------------------------------••------------a--------------------------------------• DATE------------------------------------------------------------- Alterationsand/or recommendations------------------------------------------- ...............................................------------------------------------------------------------•-------- •--------- ----------------•----•------- ..........---------- ----------------------------------------...----------•----------•-----------•---•------------•-------•---------------------. -•--------------------- -•--------------------•----------•------------•---------------------------------------------------------- RNAL INSPECTION BY: j------- --------------•. Date....... E`/ ------------•---------- ----------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 124 Sycamore Stmt 305 West 9th Street Stockton,California Lodi,California Manteca,California Tracy,California ES 9 REVISED 8-59 2M 5-62 ATLAS