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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT Permit No. .- .�.~�. ..� -------------- ------ (Complete in Duplicatel -=------------------------------------------------------- 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 d scribed. This application is made in compliance with County Ordinance No. 544. 7a�, v use JOB ADDRESS AND LOCATION_ .~.__ A�,0__R ---•- �� Owner's Name „^-�'-- f Phone. E... a------------------------------------------- Address----- ---------- ` Contractor's Name.. -4_.--,. fz-rL -------- --- Phone Installation will serve: Residence [❑ Apartment House ❑ Commercial ❑ Trailer Court [] Motel ❑ Other Number of living units:... Number of bedrooms -------- Number f baths - - Lot size ---- -�_--... ------------------- Water Supply: Public system C] Community system [-IPrivateDepth To Water Table -------- ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam 21""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 ig available within 200 feet.) � I Septic ank: Distance from nearest well--------SA--_Distance from foundation a........Mat erial--------------------------=��'.--�--�---_--E-. � ` No. of compartments �G _._ _ Capacity_/Size- _ _- Li uid dePth.--- Dispos `Field: Distance from nearest well----- ...Distance from foundatio _-_. .�_.........Distance to nearest lot line--5........... Number of lines------------ ---------7t------Length of each line----_-. - --_^sAO-_-.-.Width of trench.___...-f--_------.---� _ Type of filter material. L..,,_ -_Depth of f Iter material.---/.�'_._-------- _T length-------- ------1 ------- Seepage Pit: Distance to nearest well----------------------Distance from foundation--------------------Distance to nearest lot line................. ❑ Number of pits----------------------Lining material.......----------------Size: Diameter_....................Dept h-----------------.-__--------...- Cesspool: Distance from nearest well-----------------Distance from foundation------------.------.Lining material------------------------------------- El Size: Diameter-------------------------------------Depth----------------------------------------------------Liquid Capacity---------------------------gals. Privy: Distance from nearest well----------------------------------------- -------Distance from nearest building-__.--._--_-------_----___----.--.------. ❑ Distance to nearest lot line------------------------------------------------------------------------------------------------•----•---•-•----•--------------------------`n Remodelingand/or repairing (describe):--------- -------------•------------------•-•---------•-•--------------------------••----•----•-------•---------------------------------•----------•--•-` •----•--------------------------------------------------------------------------------------------•------------•----•-------------------------------------------•--------.-...------------------------------ •--••--•-------------------------------•----------------------••-----------------------------•-•-------•----------------------------------------------...-------------------------------•------------------------------------- --------------•-------------------------------•-------------•----------•----------------------------------------------------------•----------------------•---•---------------------•--------------------------------------- -- I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State ws, and rules and regulations of the San Joaquin Local Health District. � Signedr.>l or Contracto ( f� .... BY:------------ --- -- _ -; -- -----------------------------------------------(Title) (Plot plan, showing size of lot;location of system in relation to wells, buildings, efc., can be placed on reverse side). FOR DEPARTMENT USE ONLY q / APPLICATION ACCEPTED BY---------------------------------------------------------------------- G DATE.......... REVIEWEDBY-------------------------------------------- --------- L-------------._.- DATE------------------------------...... BUILDINGPERMIT ISSUED----------------------------------------------------------------------------------------------------- DATE------------------------------------------------------------- Alterafionsand/or recommendations:--------------------------------------------------------------------------------------------------------------------------------------------------------------- ---------------------------------------------------------------------- ----------------------------------------------------------- ------------------------------------------------------------------------------•----- -----•-----•----•------•---•-------------------•---------------- -------------------------------------------------------------•---•--------•----•--------•-----------•----------•--•--------------------•-------------------- ------ ----------------------------------------------------------------------------------•-------------------------------------------------------------------- -----•----•--------------- �r /.7 l FINAL INSPECTION BY: -==-- _.---. Date----- -- ----------- ----------- ---------------------------------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Stroh 124 Sycamore Street 205 West 91h Street Stockton,California Lodi,California Manteca,California Tracy,California ES 9 REVISED 8-59 2M 5-62 ATLAS i