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' FOR OFA r , N-14 _ a3 ----------------------- APPLICATION FOR SANITATION PERMIT Permit No. .... .7 4O_. ------ �i (Complete in Duplicate) _.. ie This Permit Expires 1 Year From Date Issued Date Issued .._... ��1�. Z✓ 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.Ordinanc N 549. 1, { _ / F JOB ADDRESS AND.LOCAT 01�---f ------ -----•-•--•-•--------- - --- ----- ------------------- ---•---•---------------- Owner's Name __ _ • U•-- -- ---------•---•---------- ---------- ----•-•------------ ...-------------------- Phone------------------------------------ �I Address :.a •----------•---- - -•-- - ------------•--- � i TV Contractor's Name f ------ - ----------- -------------------------------•-----'.._.._..... Phone ..-r, P Installatio`n will serve:, Residence ',�partment House [3 Commercial ❑ Trailer Court ❑ Motel❑' Other l/ N living F �'_ Number of bedrooms �_. Number of baths .,J_- Lot size . 0 __,�t�s. Q......................... Number of livor units: _ Water Supply. Pu blit system 0a",Com- systerri ❑ Private—[-'— Depth to Water Table Character of soil to a depth of 3feet: Sand ❑ Gravel ❑ Sandy. Loam ❑ Clay Loam ❑ Clay ❑ Adobe Hardpan ❑ Previous Application Made: (If yels,date--------------------) .No New Construction: Yes ❑ No' FHA/VA: Yes E] No ❑ TYPE OF INSTALLATION AND'SPECIFICATIONS: #. r Jam' a (No septic tank or cesspool permitted if public sewer is available within 200 feet.} a (' Kistance frorcilnearest well------______'---Distance,,from foundation....._--------------Material................................................. f No. of compartments------------------------Size-------------------------------Liquid depth---------------- ---------Capacity--••-•........._._..._. 0p isa' Distance frominearest well-----------------Distance from foundation....................Distance to nearest lot line................. Number of lines-----------------------------------Length of each line------------------------------Width of trench.!------------------------ --•--- Typa of filter'material________________________Depth of filter material----------------------Total length___.._.'.-•-•--------•............-_--•-- \ ' . '.Seepage I Distance to n6 arest well __ __ _ ____ _____Distant m foundation_- _ -�....D-stance to nearest lot line....�_�__-- y. � Number of pits...________________Lining mate Size: Diameter ��.__-.Depth�___��/_.___.______.... li . G Cesspool- Distance from : nearest well.................Distance from foundation.__._.__________.__.Lining material______...__.____________..... :_._. •-------------------------------------Depth----------------------- i Liquid CaPaci , ❑ Size: Diameter Capacity--,--------- gals. Privy: Distance from'lnearest well------_------------------------------------------Distance from nearest building________I-•-__________--------..___.____- ❑ Distance to nearest lotline------------------------------------------------------------------------ -------------------------------------- -------------- Remodelingand/or repairing (describe): ---------------------------------- ----------------------- ------------------------ ------------------------------------------------------------------------------- ----------------------------------------------------------- ----------------------------------------------------------------------------•---•• -------- ---------• •-------------------....-------------------------------•------••-------------------------------- ------ ------- I hereb certify that I he repared this application and that the work will be done in accordance with San Joaquin County ordinance , atd laws, and a end�reg lations he San Joaquin Local Health District. Si ( ned 9 ------------=--• - - —CY----- '-- ----- -- --- - --------------------------------------------------&4A nor and/or Contractor) By:r• - --- - - = = (rifle) (Plot plan, showing size of lot, locetion of system in rely o wells, buildings, etc., can be placed on reverse side). ii FO EPARTMENT USE ONLY APPLIGATION ACCEPTED BY-- = -------•----------------------- DATE 3 � �� REV i3UILID NG PERMIT ISSUED A! --------- DATE--------------- ------ - - -------------------- DATE ------------------- Alterations and/or recommenECations:-•-•--.... ------------------------------------------------------------------•--- ----------------------------------•---------------------... F �! -•--------------------- ------------------- - ---------- --- __________________________or____________________ _.__-.......-....____.___....................I--.__. e' FWAL INSPECTION -- ---------- -------------------------- Date----- ---- -- ------ ------------------------------------------------ h • --•------------------•---------------•-•-••--II SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 124 Sycamore Street 205 West 91h Street Stockton,California I Lodi,California Manteca,California Tracy,California i ES 9 REVISED B-89 2M 5-61 ATLAS �E