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FOR OFFICE USE; APPLICATION FOR SANITATION PERMIT Permit No. ..1 U.. ---- -------- --------------------------------------- (Complete in Duplicated Date Issued _I_a_-� �~ �P - -------- This Permit Expires 1 Year From Date Issued `' Application is hereby made to the San Joaquin Local Health District fol.-.a permit to construct and.install-.the work herein described. This application is made in compliance with County Ordinance No. 549. JOB ADDRESS AND LOCA ON.- f ..-, r �J^lf/ .-:....................•-•--- ....... :.:_.....-----------------•------•------....__-- Owner's Name___ _._ ----------- ---- Phone................---.............. Address._. ----•-------------------•--------------•-•-------=---------.............................................. Contractor's`Name......... --------- -----•------------------------------------------------ Phone..........................--....... Installation will serve: Residence [KAparfinent House ❑ Commercial ❑ Treiler.Court ❑ Motel ❑ Other [I 20 Number of living units: __ __ Number of bedrooms__ Number of baths; __, Lot size _A&X__ _�1_�.a._-------------------------- __ Water Supply: Public system' Community system 171 Private E] Depth ro Water Table t Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe Ug-11ardpan ❑ ` Previous,Application Made: (if yes,date--------------_.---) No R--INew Construction: Yes ❑ No a]--FHA/VA. Yes ❑ No 9�-" 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------------------------------------------...... fd No. of compartments------------- ------------Size...............................Liquid depth--------------------------Capacity..------•-------------- Dis osgl Field: Distance from nearest well_________________Distance from foundation--------------------Distance to nearest lot line................. its 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-----T- fr fou dation.-ZP'___.Distance to nearest lot line--- ®� Number of pits------ --------------Lining material_ .Size: Diameter,! --------Depth,:24;rie�_-_______--_--- Cesspool: Distance from nearest well_________________Distance from foundation--------------------Lining material___.___-____--_.__-__--------_----_- Size: Diameter._ -_____________________________De th__________._ -_Liquid Capacity gals. Privy: Distance from nearest well----------------------------------------- _______Distance from nearest building------------------------------------------ CIDistance to nearest lot line---------------------------- --------- --------------------------•--------•------•---------•----------•-•------••--------------------- Remodeling and/or repairing (describe)- ---------- .........---------... ------------------------------•---- •-------I-------•-------------•----------•-----------------------••-•----•-------- ---------------------------------------------- ------•-------------------------------------------------------------------------------------------------------- ---------------------------------------------- --- 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 of the San Joaquin Local Health District. (Signed)-------------•----" • - --------- -- ------ --- ------------------- - ---- �(@ �Confiractar) By=----------•----------------•--------------------=------------ - `--------------(Title)---- �7�1- (Plot plan, showing size of lot, location of syst in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED' BY_`_": -----------------------•--------------------------------------- DATE.--. REVIEWEDBY------------------------------- ----- -------•------------------•-------------- -------------------------------------------- DATE--------- ------------------------------------------------- BUILDINGPERMIT ISSUED--------------•--••---------------------------------------------------------------------------------- DATE------------------------------------------------------------- Alferafions and or recgmmend'ations:- --- -------- ---------------•-------------------------•-----------.------------• ---------------- .- c .�� FINAL INSPECTION BY:---- --------- ---- 4 Date-------------Z-r��/ SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 124 Sycamore Stmt 205 West 91h Street Stockton,California Lodi,California Manteca,California Tracy,California E5 9 REVISED 8.59 2M 5-62 ATLAS