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_ �� FOR OFF1 E USF �- 5/`/G .__..- --------------------------------- APPLICATION FOR SANITATION PERMIT Permit No. .._'_` . ...�... ------------ -•--- ------ (Complete in Duplicate) S– Z� --------------------______________---________-____.__ 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 LO TION• 1-d l7� �7 ----------s ----•----•----------=----------------------- Owner's Name-------------- - _----• ----- Phone... ..Q._ . Address---------------------- --------G.! `�"rl` --------.......................•------------------.-.---------•------...-----.....--------------------.......----•------------------•------... Contractor's Name------------------ - •-------------------- ------------------------------------------............................ Phone...............----•-----..-.------ Installation will serve: Residence Apartment House ❑ Commercial �T�r�ailer C urt [:] Motel El Other ❑ Number of living units: __�____ Number of bedrooms ___/__ Number of baths __A.. Lot size ••--___..�_�. �(.-1.l1�._....................a Water Supply: Public system ❑ Community system ❑ Private Depth to Water Table -------- ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe Hardpan1-7 ❑ � ' Previous Application Made: {If yes,date____________________) No V New Construction- Yes ❑ No FHA/VA: Yes ❑ No TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Soptic Tank: Distance from nearest well--3'i2-------- Distance frtim foundation____,ll�._.....__.Material____ No. of compartments--------r�_____________Size_____ _-�C: .___,__.Liquid depth 6. Capacity-.- Z_�3__ W Disposal Field: Distance from nearest well----:,�17......Distance from foundation._-/.f1___...!_.Distance to nearest lot line___._____ `� Number of lines......... Length of each line__.1-0.,----.-Z12----.Width of trench______ .-.-...---.-.----.-- `� Type of filter material._ Depth of filter material-------)_5-r-- --_Total length.........g•s'a---_------------------ ___ Seepage Pit: Distance to nearest well----------------------Distance from foundation....................Distance to nearest lot line................. ❑ Number of pits----------------------Lining material-----------------------Size: Diameter..........--------------Depth----_-.--.----_----------------_. Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material__._-_________----_._-_-_-_____-____. ❑ Size: Diameter Depth = �--------------------------------Liquid Capacity................------------gals. Privy: Distance from nearest well-___________________ ___________________________Distance from nearest building.._...------------------------------------ ❑ Distance to nearest lot line--- ------=--------------"-- ------ -------------------------------•----•-------------•--------.......-------------------------------------- Remodeling a /or repairing (des ibe}:_ .-- - ,, _ ' _-- r - `�_ .. ... .........•--t.-..-. ----------- --- -- hereby, certify that I have prepared t s application and at the work will be done in accordance with San Joaquin County or nan es, State laws, and rules and regulations of the San Joaquin Local Health District. 6 {Signed- �' ! � -------------------------------------------------.-_.(Owner and/or Contractor} By----------------............---------------------------------------------------------------------------------------------------------{T-rtle).-------•--•------- -------•------------- ---------------- (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---- DATE Z REVIEWEDBY-------------------------------- ---------------------------------------------------------------------------•------------- DATE----------•--••---•........................................ BUILDINGPERMIT ISSUED---------------------------------h--�;;....__ -- --------------------- -------------- DAT�---------------------.---------------------- ....... Stu Alterations a or rete d. t. -Y es �"�`. :.-------- � + ...... ------•-•- `'` -- ��;•• ---- -- _—.- -- -------�-- - _------ ....................-''"` s ...?tom - "�k ' .-----�� ,-- al'.1 ._.1.. �y��:. :-z----------------------- FINAL INSPECTION BY: :.. Dete - 2 _{p ---•----•----- ------------------------•---•--- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 Went Oak Strool 124 Sycamore Street 205 Weil 9th Street Stockton,California Lodi,California Manteca,California Tracy,California E6 9 REVISED R-69 291 6-6t ATLAS