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FOR OFFICE USE: - -- ------ -- -- -- / �3 -- ----- -- - -- r-- --. --_ _k- APPLICATION FOR SANITATION PERMIT Permit No. ............. 1_i r{----------- (Complete in Duplicate) J 3 ( �- __ _- ----_............. ................_--._._. 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 described. This application is made in compliance with County Ordinance No. 549. JOB ADDRESS AND LOCATION-------- ----- ----------------------•------------------------- ...... Owner's Name.... ��,�� +� -: -------- Address -------------- Phone.// - - ------------ --------------- ----- -- ---- -- --------- - Address--•--•--------------------------•--- ...............cam------------1�;, ------------------............I-------------- .............................................. Contractor's Name----------------- .......----- - j-------------------------------------------------------------------- Phone----"- •-•----•--------•- - - - -- Installation will serve: Residence ® Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: __/___ Number of bedrooms ___?::-Number of baths ----Z_ Lot size ----______- r ---..------- Water Supply: Public system ❑ Community 'system ❑ Private j Depth To Water Table Z/'" 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 E3-'�New Construction: Yes ❑ No �FHA/VA: Yes ❑ NO-E] 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___:Z --Distance from foundation_____.3_5F....__.Material---- _"_____________------------------------- No. ___•--_---"----__-____.No. of compartments_________'!) Size------ Liquid depth____.__-S7__------------Capacity...... Disposal Field: Distance from nearest well- a°a___Distance from foundation____/.d........Distance to nearest lot line.____L__----.." Number of lines-------________/_ -------------Length of each line----------- _:-D Width of trench----------------z---�___----- Type of filter material._._ v____Depth of filter material____.,1�_--------Total length______________ ----------------- j Seepage Pit: Distance to nearest well-----/_�17_____Distance from foundation----/_3._-....Distance to nearest lot Number of pits-------/-----------Lining material__ -xrr_efe!�_.5ize: Diameter----.-.7.,-,3---------Depth-------- -yz----'-------.--- Cesspool: Distance from nearest well------------------Distance from foundation--------------------Lining material___.__._____-______.____....._.._.___ ❑ Size: Diameter-----------------------------------•-Qepth----------------------- --- ------._Liquid Capacity.............---------------gals. Privy: Distance from nearest well-------------------------------------------- from nearest building_______________..___._________---._____._. ❑ Distance to nearest lot line--------------------------------------------------------------------------------------------------"--••-----------------------------•-------- 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 laws, and rules and regulations of the San Joaquin Local Health District. (Signed)---` - ----------------------------------------------------------- -----(Owner and/or Contractor) By:_ �. (Title) ----•--------- (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY j APPLICATION ACCEPTED BY------------ -------------------------------------- DATE------------------ ./ ~---------- f REVIEWEDBY-----------------------•--•----------------- ---------------------------------------•------------------------------ •--...... DATE------------------------------------------------------------ BUILDINGPERMIT ISSUED----•-•------------------------------ --•------------------•-- __- ------------------------------. DATE--------------------•---•------------------------------------ Aiteratioi and or recommendations----------------------"-- --- ------------------------- ----- •--------------- ---:__� i-a.��• �'---- _�n__�-----------------` - �.:: c - a '" --- - ------ --- l d------------------------------------------------- - w ✓,�/ X---- --. ... . -- - - FINALINSPECTION BY--------- --- --- -•------ -----------------• --------------- Date----------------------------------_...------------------------------------------ � 1 SAN JOAQUIN LOCAL HEALTH DISTRICT I � 130 South American Street 300 West Oak Street 124 Sycamore Street 205 West 91h Street Stockton,California Lodi,California Manteca,California Tracy,California r E5 9 REVISED 8.59 2M 5-62 ATLAS