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FOR OFFICE USE: ' Y -------------------------------------------------•_-- APPLICATION'FOR SANITATION PERMIT Permit No. �.:. �' (Complete in Duplicate) This Permit Ex ires I Year From Date Issued Date Issued . _ oss— �-v—f 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. cT3o ' ' . JOB ADDRESS AND Owner's Name------- i Phone.................................... 01 Address............... ., ------13 3 3 ' ..------/-?±�'------------------------------------•--•-----•--------.---------------•--••---•-------.....---------•--.._..-•---...... Contractor's Name-Z... ---------•--------------------------------------------•-•-•..........I.....-------------.......... Phone................................... Installation will serve: Residence ❑� Apartment House F] Commercial ❑ Trailer Court E] Motel [:] Other [U*. .Nn Number of living units: -------- Number of bedrooms _______ Number of baths ___L__ Lot size . 5_____________________-___----_---.---_-_-- Water Supply: Public system ❑ Community system ❑ Private © Depth To Water Table .!_S". ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ® Clay Loam ❑ Clay ❑ Adobe❑ Hardpan ❑ i Previous Application Made: (if yes,date--------------------) No [.] New Construction: Yes 110 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 well-ATP........Distance from foundation—_19.._._____..Material...__[mm-114,L---•____________________ �] No. of compartments------V---------------Size: --�x--$..........Liquid depth__..._----------------Capacity--- fQ -------- ,\ Disposal Field, Distance from nearest well__-P---------Distance from foundation.j.Q.............Distance to nearest lot line-Sl W ! ® Number of lines_ --------Length of each line------FA-------------------Width of trench.._.on-J'%---.-----_----_-- Type of filter material�i ,_ :_ Depth of filter material___1_g -------------Total length___---.--------•___________________ w Seepage Pit: Distance to near i?st well_ ______________ _-Distance from foundation-------------------_Distance to nearest lot line----------------- El Number of pitsA------------------Lining material.--------------------.-Size: Diameter------------------------Dept h.....................-. -------- Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material----------------------------- ........ ❑ Size: Diameter--- --------------------------------'Depth---------------------------------------------------Liquid Capacity----------------------------gals. I Privy: Distance from nearest well----------------------------------------- ______Distance from nearest building___.__.____________._.....______..____._. G ❑ Distance to nearest lot line------------••-------------------- Remodeling and/or repairing (describe):__---------------------------- --------------_--------------------------•----.....--------•.----------------------------------.-------------------- -----------------------------------------------------------------------•--------•--------------...--------------------•------------------------------ ------------------------------------------.------------------------------ ---------------------------------------------------------------l------------------------------------------------------- ------------------------------------------------------------------------------------------- ---------- i 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 e d regulations of the San Joaquin Local Health District. (Signed)------------ ...1----V770 -----------------------------------------------------------------------------------------------(Owner and/or Contractor) J By:--------------------------......---------------------------------- -----------------------------------------------------------(Title)---------------------------- --------------- ------------------ (Plot pian, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). I FOR DEPARTMENT USE ONLY a APPLICATION ACCEPTED BY... -- •-- O ------ --------------------------------------------------•-------- DATE... REVIEWED BY---------------------- BUILDING PERMIT ISSUED---- - " DATE -;---------------------••----•.--------------------------------------•----•----------- DATE------------------------------------------------------------- 1 Alterations and/or recommendations:I ------------------------------- ----------•----•----------•-------.--•-----••-•----•---•--•------ ... i 1 --------------------------------------------------------------- ------- --------------------------------------------------....--------------------------------------- ---------------------•----------- -----------•-•-•---•---------------- -•--------------••--------- - --------------------------------------------...-..-------------------••-•-•------------------------------•---------------••------------- ----------------------------•------- ------------------ -•----------------- •------ ---------------•--••-•-----•----------------------•------------------------ -------------------------- FINAL INSPECTION BY:- - - ! - - ------------------- Date------- � -7-G --------------------------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 124 Sycamore Street 105 West 9th Street Stockton,California Lodi,California Manteca,California Tracy,California ES 9 REVISED B-59 2M 5-62 ATLAS a e