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FOR OFFICE USE: ---------------='-------------- ----- ------- � .1�4y,._c _._ APPLICATION FOR SANITATION PERMIT Permit No. _i_ v.. `_.. --------------•------•------------------------------- - (Complete in Duplicate) tq -Cn 'L - ( P P� } Date issued .�.`.----••----_---- -----------------_____.............. -------------------- This Permit_EUires i 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 County Ordinance No. 549. �/ JOB ADDRESS AND LOCATIO ---.�.- --�-I------e'---10----------------------•--•-••---•-- -- -•----- ._ ------------ --------------------------------------------- Owner's Name_--.lam- •--•--------•--•------ -------•- -•-- ------ Phone........---------------- •----------------------- ---------• ----....._. Address--------.. K I-1-:_� ---- ----------- ---•------------------------- ----------...----------------.....----------- p �-� -- -- - -------- Contractor's Name------ ` a h _ -••---•---------------------------------•------------------••--•-•-------••-----------•---------_- Phone................................... Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: ---I--- Number of bedrooms ._2._ Number of baths __t___. Lot size ----1J-=-XJA-9________________________________ Water Supply: Public system 2---6-0mmunity system ❑ Private ❑ Depth To Water Table.4(0_ ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe n-"Hardpan ❑ Previous Application Made: (if yes,dote____________________) No New Construction� Yes Ey"'No ❑ FHA/VA: Yes ❑ No f TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Sep ' Tar Distance from nearest well-----------------Distance from foundation-----------------._.Material_____.._________--_--._--.-- ____:____.____- � � No. of compartments--------------------------Size---•----------------------------Liquid depth------------- ------------Capacity.-_----------------•- Dlsp j_Fieldi Distance from nearest well_________________Distance from foundation.........-----------Distance to nearest lot line.__________-_•--- r*-�j Number of lines-----------------------------------Length of each line---------------------------.-.Width of french--------_---------------------_.--. Type of filter material--------------------------Depth of filter material-----------------------Total length.....................---------------r---- \ �g Seeps Pit: Distance to nearest well_�r�.______Distance from foundation--SLF__t........Distance to nearest lot linesa�__-._._ w Number of pits__-1--------------- Lining mate rial�0G/.(-----Size: Diameter...si -------------Depth---------Z4.... ---------- 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--------- -------------------------------------------------- ---------•------------ q Remodeling and/or repairing (describe):-------------------------------------------------•--.---------------------------------------------------------------------------------------------------- ---------------------------------------------------------------------------------.-----------•---------------------------------------•--------------------••------------------------------•--------•---------------------- ----------------------------------------------------------•----------------------------------------------------------------------..........---------------------------------------------------------------- ---------------- I hereby certify that I have prffreati plication and that the work will be done in accordance with San Joaquin County ordinances, State laws, and rules an San Joaquin Local Health District. (Signed)------------------------------------- ------- ------------- •---------------•----.(Owner and/or Contractor) By:--•------------------- ----- --------- --------- (rtle)..... --------------------------------------- (Plot plan, showing size of lot, ion of system to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY-At-_-W.. -__W. __ DATE --------- - REVIEWED BY--------------------------------------------- ---------------- DATET---------- -- BUILDING PERMIT ISSUED----------------------------------------------------------------------------------------------------- DATE------------------------------------------------------------ Alterationsand/or recommendations:-------------------------- ----------------------------------------------------------------------•--•----•--••--•------•-•---•--------•-------------•-••------ - --------------------------------------------------------------------•------------ -------- -•----•--------- ---•---------•------------------------- -. --------- --------------- ------------- --•------------- � 4 FINAL INSPECTION BY----------- --- Date----- ------------- ............. --- -- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,California Manteca,California Tracy,California ES 9 REVISED B-59 2M 5-62 ATLAS