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rvrc Vrrit,.t uJt: .11 ---------------------------------------------------- Ar�, itICATION FOR SANITATION PERMIT Permit No. .;. ?-_5__4::'__�- - ---- --------------•-------- --------------- (Complete in Duplicate) ? - r____________________..---..-_-_.--__...-.-.--..-.- 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. ' 6 9--v---------------------•---------1 -----------------•-••---- JOB AD—DRE✓SS AND LOCATION._ _ tea =C-` Phone' ...��_.r.--Owner's Name- .----- -------------------------------------- -.-- --.-_-- •-=•---f Address . P jZ t, E = � i ' . 4S �'.- Phone.A&._Contractor's Name =--------------------------------- Installation will serve: Residence ❑�artment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: =-_---_ Number of bedrooms -:7�7Number of baths -------. Lot size - .......... + Water Supply: Public system ❑ Community system ❑ Private R Depth To Water Table ........ ft. J �~ Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ dobe[3- Hardpan ❑ FPrevious Application Made: (if yes,date--------_------------) No ❑ New Construction: Yes ❑ No 12 FHA/VA: Yes ❑ No ❑ 4 TYPE OF INSTALLATION AND SPECIFICATIONS: F1 �l(No septic tank or cesspool permitted if public sewer is available within 200 feet.) S'sptic `..., Tank:--. ..--... ..... Distance from nearest well-----------------Dis#ante from foundation--------.--...-.-. Material-------------•--•--- ............... 1, Ir.,---,, --------------------------of compartments--------•-----------------Size--------------•-----------------Liquid depth Capacity :: Dis" osal_ Distance from nearest well..l. 3- - -.-Distance from foundation.. ? '�.-... P + 1 ......Distance to nearest lot line.-J.... �. F y*' Number of lines...'- -Len Length of each line- -gym �_-_1-.3--.Width of Clench.- . -- _'�-.---__----_-- ❑ 9 .lw- s- Type of filter materialr.i/_St.-I"-I" ---.Depth of filter material_-4F'-f:<---.-._Total length-------- __�- /------------- Seepago-Pit: Distance to nearest well---------------------- from foundation--------------------Distance to nearest lot line--------------- _ -j Number of pits---------- ------Lining material-----------------------Size: Diameter------------------.----.Depth-----------------•--------------- O Cesspool: Distance from nearest well-----------------Distance from foundation_-------------------Lining material--..---.-----.-----.-_----------_---. ❑ Size: Diameter--------------------------------------Depth------------------------------ -------------------..Liquid Capacity----------------------------gals. m Privy: Distance from nearest well----------------------------------_---- -------Distance from nearest building._--.--.--_.__-.--._...._.-._..-..-----. g ❑ Distance to nearest lot line----- -- -------------------------------------------------------------•------•-------------------------•--••-•---------------------------- 1 F Remodeling and/or repairing (describe ; ---------------- ==' :...--. = , ----•-----•------------------------------------ ------------------- ------------------------------------------- e t c' rte' ------•--------------------------------------------------------------------------------------------• -------------•---------------------------------- - I hereby certify that I have prepared this application and that 4work will be done in accordance with San Joaquin County ( ordinances, State I ws, and rules..and regulations - r of the�San Joaquin Local HearDistrict. = "$erend/or Contractor)�= "=St ned t , BY: _ �---'�: �--------- (Title) - - (Plot plan, showing size of lot, location of system in relation #o wells, buildings, etc., can be placed on reverse side). # ( FOR DEPARTMENT USE ONLY f APPLICATION ACCEPTED B,,.-- --- ------------------------------------ DATE.�� :-- � _.-.... ---•---- REVIEWEDBY----------- -------------- -------r-------- ----f/---------- -----------------•-------------------------------.-. DATE------------------------------------------------------------ BUILDINGPERMIT ISSUED------------ --- =------------- ---------------------------------------------------- DATE------- ------------------------------------------------ Alterationsand/or recommendations:-------------- ---------------------------- - ------------------------•--•------------------...---------- --------------------•---------•........---•------- .-..---•---•-------•----------------------------------------------------------------------------------------------------•------ ----,----------------------•------- ,---------------•-•----------------------------------.. ----------•----------------------------------------------------- '---- + ---------------------------- ------------ - ----------------------------------------..---- ----------. ..------ r ------------------------------------------- --------------------- , I--- , _�� FINAL INSPECTION BY:.....-_..�----- - Date---�------ --------- -------------------- i l SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stock}on,California Lodi,California Manteca,California Tracy,California E5 4 REVISED 5-59 2M 9-52 ATLAS