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10' UK ----- 2 APPLICATION FOR SANITATION PERMIT Permit No. ___/__. ------------- -------- ---------------------------• [Complete in Duplicate) Date Issued ------- ----------- ----- ---------------- - --�---- -- This Permit Expires t Year From 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 ou ty Ordinance No. 49. l f JOB ADDRESS AND AT ---- ON-- X` _;� Y `... _ ----- ----- Owner's Name Phone Address- 3 -�_. 7�D r - - --•- Contractor's Name... ---•----- ---------------••-------------------•----------------------•------------- Phone................................... 1{- Installation will serve: Residence ( !Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: ---I--- Number of bedrooms _Z__ Number•of baths ----I.. Lot size ---- _g ------- Water Supply: Public system [ Community system ❑ Private [-] Depth To Water Table .z-/- ft. \`�1 Character of soil to a depth of 3 feet: Sand❑ Gravel [-] Sandy Loam [3 Clay Loam [3 Clay [-] Adobe'E]-�H5rdpan C] \4 Previous Application Made: (If yes,date___________________) No New Construction: Yes Ej 1YO ❑ FHA/VA: Yes ❑ No ❑ �=i TYPE OF INSTALLATION AND SPECIFICATIONS: `v (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tank: Distance from nearest well------D stance from foundation-2-4! 'I �+ •----M t ria!_C'C�_ ��C ---..�------ [ 1 No. of compartments---------Z�____.___-Size____-. -X �_Liquid depth - � Ca aci rte- Disposal Field: Distance from nearest well`----------------Distance from foundation �.r______ line -.. Distance to nearest lot -.._-___-__-•- Number of lines___________ __ Length of each line-------5,f'-.�2__-____-_____-Width of trench.: , 9 Type of filter mate ria l._r�<J<__._--Depth of filter material____ ��_ g !J% Total length -------------------------- __ ..._.___.. Seepage Pit: Distance to nearest well---- ---Distant rem __ ation__._ d.�_-.Distance to nearest lot lint_ + [ � Number of pits-----------�.__.:__---Lining material _.______. -' . ize: Diameter_--_-�_- ---- Depth__..__..____. Cesspool: Distance from nearest well-------_____ Distan oundation--------------------Lining material----------..-.-________--______._._ ❑ Size: Diameter---------------------- -------------•-Depth----------------------------------------------------Liquid Capacity- ------------------••------gals. Privy: Distance from nearest well-------------------------------------------------Distance from nearest buildin ❑ Distance to nearest lot line Remodeling and/or repairing (describe)----------------•---- --------_ � _ [. .--.. _ _ �.� ----•--•-•_--_- -------•- r._. --------------- ---------••--------------------_--.-------•--------------•---•-- ------------------------- --------------------•••--- ---••-------------------------------------••----------••------------------•---------------•--------------------- -----------••---------------- hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State la , d rules and r Mations of the San Joaquin Local Health District. [Signed}. era C } t -•--- -------- -- -- -- - or on rat or <. --- ---- - - �-1 . _ --(Owner n ay:. ------ ---- -- Title (Plot plan, showing size of lot, locationo s tem in relation to wells, buildings„efe., can be placed on reverse side). ^- FOR DEPA MENT USE ONLY APPLICATION ACCEPTED B REVIEWED BY --- -- - ---- ---- -- - _ DATE__ -- - --•----------------------••--- DATE BUILDING PERMIT ISSUED-------------------- - D ---=, -------------- - Alterations and/or recommendations•. �_ -__--;___.-----,._�-_ -•- =z✓_ �� l -------- ----------................................... ----•- ------------- Y FINAL INSPECTION BY ----- --• ---- --------- ----- Date`xl<, ----------------------- SAN JO IN LOC HEALTH DISTRICT 130 South American Street { t k 300 West Oak Street 124 Sycamore Street 205 West 91h Street Stockton,California Lodi,California Manteca,California Tracy,California ES 9 REVISED a-59 2M 5-$4 ATLAS