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FOR OFFICE USE: ! 77/ 76 r -- --------------- J ___________________ _*. _ ___-_--__._. PPLfCATION FOR SANITATION PERMIT Permit No. ...�.`�. .._3.�- -------------------�.----- -.-.s---- -------- (__61' G-� � �� (Complete in Duplicate) ,,�rZ,��Z `� -- - This Permit Ex ires I Year From Date Issued 1 I/ Date Issued ....................... ` � � �., a Application is hereby made to the San Joaquin Local Health District for a permit to construcl and install the work herein described. This application is made in compliance with County Ordinance No. 549. JOB ADDRESS AND LOCATEON_ , ��4,f,&4-(13,3 �5 rfiiv ._ rrl- 11t_, '�.Q <.!P�F _ r �� - ----�4- IWAV Owner's Name-- -• ---- 1. ----- •-- -------•------------------- Phone.................................... Address-----••------�..... ...--- = = ---•-----• . •--•-•.... Phone Contractors Name------ - •• --••------------------------------------------------------------------- •- -- - - - Installation will serve: Residence ❑ Apartment House ❑ Commercial ❑ Trailer Court 8<Motel ❑ Other ❑ Number of living units: '_ Number of bedrooms;'___ Number of baths ._/___ Lot size _YAM-1-�.'.................................. Water Supply: Public system ❑ Community system ❑ Private [Depth to Water Table 01% . d Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay,Loam ❑ Clay ❑ Adobe ff. ardpan ❑ Previous Application Made: llf yes,date--------------------) No U30' New Construction: Yes ❑ No [ HA/VA: Yes❑ No t _f TYPE OF INSTALLATION AND SPECIFICATIONS: N (No septic tank or cesspool permitted if public sewer is available within 200 feet.) V) SP tic Ta k:" Distance from nearest well-----------------Distance from foundation-------------------Material....---------------------------------------------- �j6lri0* No. of compartments--------------------------Size---------------------------------Liquid depth--------------------------Capacity--------------__-- Disposal ----------•--..._. -Disposal Field: Distance from nearest well-----------------Distance from foundation--------------------Distance to nearest Jot line__-____-----_•.-- )!�5W5IW Number of lines------------•----------------------Length of each line-------•--------•--.-_----.._.Width of trench----.-- . .-•- _-----------_ Type of filter material.___________________--.__Depth of filter.material------`___-_____.____.Total length____......... .._.._._t___________..__-- SegpageL Pit: Distance to nearest well_- --_----Distance f om f undation__�'..__Disptance to nearest lot line_��s___-. C� �i �ry Number of pits--,,./ Linin material_xp�___._Size-.Diameter_.__Ole!i/--------Depth_____________________ Ces o Distance from nearest well_________________Distance from foundation___:__:____________.Lining material___.____:..-___-.;--:-•--_-_________ ❑ Size: Diameter--------------------------------------Depth---•------ -----------------------------------------Liquid Capacity---------------•----•-------gals. Privy: Distance from nearest well----------------------------------------- _______Distance from nearest building------------------------------------------ Cl Distance to nearest lot line--------------------------------- ------------- -- -----• . --•--- ------_-------------------- Remodeling and/or repairing (describe)--------------�'"a • •---------------------....•--••• , ................................ --------------- ....... ........ ........ •-- ---------------------•----.....- ................... -----....--••-------------•--•-------••-----•-------•---.._...--.1-_.__. --------------- -----------•------ ---------------•----•----------------------------------------•--•------------------------------•------- 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 nd regulations of the San Joaquin Local Health District. (Signed)-------- ��v - _ A. Contractor] By:-------------------------------------------- - ------ --- '-(Title)---- ------------ -------------------- (Plot plan, showing size of lot, location of system in relatio wells, buildings, etc., can be placed on reverse side). FOR DEPORTMENT USE ONLY APPLICATION ACCEPTED ---- DATE-------Y__ -------(Iel. --- '- - REVIEWEDBY -•----.... ---•------------------------------------------------------------------------------------------------- DATE----------------------- ----------•----------------•------- BUILDINGPERMIT ISSUED-----------------------------------------------------------------------------------------------• •- DATE----------------------------------------------------- Aand/or recornmendations-----------------------------•----------------------•-----••-•---------------------------------------------------•-•--•-----------... ---------------• ----- ---- -------------------------------•---------•------•--•------------------•--•------------------------------•- --------- -- -------------------------•--------------------------------------------------------------•---••---..........--------------...----------_----•----------•........... -- •--------------------•--•--------...-----•--•-----------------------•----•-•-----•---•----------•------------ FINAL INSPECTION BY:. -.�:. � ''' - Date-------- h t SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Strut 300 West Oak Srreei 124 Sycamore Street 205 West 91h Street Stockton,California Lodi,California Montsca,California Tracy,California E8 9 REVISED 8.59 @M 5-61 ATLAS - -