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FUKUFFICE USE: ----------------------------- ---------- --------------------------------- -------- I ---------------------------------- ----------- APPLI ATION FOR SANITATION PERMIT Permit No. _--1..h.- ?— (Complete in Duplicate) �S ----------------------------------- ------- / Thi Permit C--:.-- 1 Year From Date Issued Date Issued /--.?ji j''____ _ Application is hereby mbme to the San Joa In 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 LOCATION -"-- ----- - `�T" � A n�; V� - lk'� Owner's Name____ / IF = r9' ---- ---••----------------- phone------------------------------------ Address `:- --------------------------------------__-------------------------------------------------•----- Contractor's Name.�?,1.,eax.�t�et _ ^*! `�`� 4°---• --- ------ Phone...................---------------- ----------------------------------------- Installation will serve: Residence ❑ Apartment House ❑ Commercial ❑ Trailer ASeeM 4B Motel ❑ Other ❑ i - Number of living units: .1---- Number of bedrooms .-y__ Number of baths ________ Lot size ------ .................................... Water Supply: Public system [I Community system ❑ Private,E] Depth ro Water Table 1%'r ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe❑ Hardpan ❑ Previous Application Made: (If yes,date--------------------) No ® 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.) Septic Tank: Distance from nearest weil_,_J"O---------Distance from foundation-101 Material. --------------------------------- No. ...... _____________No. of compartments___ ______________________Size_- .'_' _�_�_. Liquid depth_________._-___.__.,Capacity. Disposal Field: Distance from nearest well__7"P--------Distance from foundation..le.............Distance to nearest lot line:. . , AN, j �] Number of lines....1________________ __.____-_Length of each line_____!A-�._____________---Width of trench-Ay ----------------------- Type of filter materiaf�_ �i�C_.___Qepth of filter material----Z_P"-----------Total' IengtKadil_______-----------_------------ Seepage Pit: Distance to nearest well____________________Distance from foundation______._________._..Distance to nearest lot line---------------_ ❑ Number of pits---------------------ILining material----- ----------_-------Size: Diameter------------------------Depth--------------------------------- Cesspool: Distance from nearest well------- Distance from foundation-----_--------------Lining material_-____.______________________________ ❑ Size: Diameter-- I ---._Depth----------------------------------------------------Liquid Capacity---------..................gals. Privy: Distance from nearest well-----__!_------------------------------- -__-__Distance from nearest building-______._________________________._____._. ❑ Distance-to nearesf lot line_tkl--__________`_____________________ _ ______ s --------------- ----------------,------_--•----------------------------------- Remodelingand/or repairing (describe):----------------------------- ----------------•-• - ----------------i ------•--------•----'-- ---------------------------- ...............•. -----•-------------------------••--•--------......_-------`----------------- ------ i I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, to laws, and rules and regulations of the San Joaquin Local Health District. (Signed --- -- ----- ------------------------------------------------------------••-----------(Owner end/o`r Contractorl --•- ---•• (Title) �t.� --------------- (Plot plan, sh Ing size of lot, laca n of system in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY sore 1W, APPLICATION ACCEPTED BY _________ DATE_._ _'1d� _--_______ .___ ._ ------------------------ -- - ---------------- REVIEWEDBY------------------------------------------------------------------------------------------------------------------------------ DATE------------------------------------._. >----•-...--- BUILDINGPERMIT ISSUED----- --------•------------------------•---------------------•--------------------------------------- DATE-------------------------•--- -------- ----------------- Alterations and/or recommendations:---------------------------- --- -------------...............................................................................*- •------------ ---------------------- --------------------------------------------------•- -•-•--------------------------------------------•----------------------------------•---------------------------------------------------------- _`--------- -------------------- •-------•----•-------- ---------------------------------__-----••----.._.------------------•--•--.._._..-....._-. --------•----- -------- :r._------ _.......-- ............ ------------ --- ----------------•--------------------------------------------------------------------•--------•- -- ----- -------- FINAL INSPECTION BY:/f,� s -------•-•- -.. Date..... .I— --------- 41 SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 Wast Oak Street 124 Sycamore Street 205 West 91h Street Stockton,California Lodi,California Manteca,California Tracy,California ES 9 REVISED 8-59 2M 5-62 ATLAS