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FOR OFFICE USE: --------------------------------------------------------- / -------- APPLICATION APPLICATION FOR SANITATION PERMIT Permit No. _ �...�]. .b - ------------------------------------------------------ [Complete in Duplicate) Date Issued ------------------------------I------------------ --- This Permit Expires 1 Year From Date Issued ----------..��_6� Application is hereby made to the San Joaquin Local Heal+h District for a permit to construe .enstall+he work herein described. This application is made in compliance with County Ordinance No. 549. 0,5-1— 200-7/ JOB ADDRESS ANDUOCATI-ON,, - _"-.. �.�... f .0 ' • / __71--- ............Owrer's Name � �AddressQ .---. . P Contractor's Name-------- ------------------------------------------•-•-----..__..-_ Phone............................ Installation will serve: Residence House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: __` Number of bedrooms . --. Number of baths 4'... Lot size -__ ----------------=-------------- Water Supply: Public system ❑ Community system ❑ Private ® Depth To Water Table _ ► ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam k Clay Loam ❑ Clay ❑ Adobe❑ Hardpan ❑ Previous Application Made: (If yes,date____________________l No Q0 New Construction: Yes T No ❑ FHA/VA: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) W ' Septic Tank: Distance from nearest welh__ 0___Dista e fro -fou dation__._4_.______.Ma rial__� _ _________ _____________ No. of compartments ''}� f � pSize_- __7.:�•_-7�_�y__.Liquid depth---•----------------------Capacity. ...'._.._..__. + c��I:� Disposal Field: Distance from nearest well-4--P-____:_Distance from foundation__Xa............Distance to nearest lot ........ (111 Number of lines--- ___ ___ _ ________ en th of each line_______�_____-___-__-_.__-Width of trench._ �`---_____.__-_-____--_ - Type of filter mate is Depth of filter material----/Ro--.-______-Total length___ __�a"4_�__________________________ Seepage Pit: Distance to nearest well----------------- D stance from foundation-------------------Distance to nearest lot line__-_________-____ ❑ Number of pits:-----A--------------Lining material-..-----..----.--_A---Size. Diameter------------------------Depth---------------------_--.-----. 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_---------------------------------------------------------------------,-----------------------------------------------------------••--- Remodeling and/or repairing (describe):--------------- •------•---•---•--- ------------•----------•---------------••--•--- ' I ---••----•--••-----•---------------------j +�l Z----4'"----��-a"u- _... --!--?---------••---------•--•--------------------•------------•----.---------•--•--------------------------------- --•---•-----•-•--------------------------------•------------•-------------•---•----------------------------------.-..----....--•---------...--------------------....--------------------------•----------------------------- 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 and regulations of the San Joaquin Local Health District. (Signed)..--• ------------------------------ ------•--------....-------------------------------- {Owner and/or Contractor{ Plot Ian, showing size of lot, oca+ion of s s+em in relatio [Title)---------___________-------__: . . _.-------------- ------------------------------ �^-__-. BY� - - -- ------------------------------ Antle) p g y n'to we Is, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED $Y ----------------------------------------------------------- ------------------------ i REVIEWED BY----- ---------•----- ----------- DATE--------------------------------------------------I-------- ` BUILDING PERMIT ISSUED------•-----••-•------------------------------------------------------------------------------------- DATE-----------------------------------------------7i--------- Alterations and/or recommendations:----------------------------------- ------------------------'3.o______-___- ----------------•-------•--------------------------------------• ---•--•----------•-•-----•----------•---•---••------•------------------- Date----' e `G' - FINAL INSPECTION BY:...___ --- . -------- SAN JOAQUIN-LOCAL HEALTH DISTRICT _41 !(6 tLb 130 South American Street 300 West Oak Srreet 124 Sycamore Street 305 West 9th Street $a0 Stockton,California Lodi,California Manteca,California Tracy,California ES 9 REVISED B-59 21A 5-62 ATLAS ' '