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FOR OFFI E USF " I! f/ Permit No. ...I` r��t ------- �------------ - - -----------j---.- APPLICATION FOR SANITATION PERMIT -------------------------------------------------- (Complete in Duplicate) Date Issued --- ------------------- This Permit Expires 1 Year From Date Issued _�.`...... . Application is hereby made to the San Joaquin Local Heal#h 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 CON. _ 40••---•.........--•-•------.._.. ...----.---- 1------L� � Owner's Name------------ tATI ..{.. ----.- Phone.- _...•-----•------------------Address..................... ...... -..- Contractor's Name---------- i� ------------ Phone------------------•--•---•••------ Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other E]: Number of living units: __k m� ,�. . " f Number of bedrooms _ ^°_ Number of baths�� Lot size ....-•-----------------=-- Water Supply: Public system ❑ Community-system ❑ Private lyDepth To Water Table SW ft. Character of soil to a depth of 3 feet: f,Sand[] Gravel Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe H'�dpen ❑ �3 Previous Application Made: (If yes,date-._..._---_-._-__) +No � New Construction: Yes �No ❑ FHA/VA: Yes [ 'No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: w . ( PcesspoolP p feet.) Septic Tankse septic tank nearest well_ sa�LD+s#a ce f om foundation_ e r ' ed i4 public sewer is available within 200 f/ �s dt Material �� �,,�► v Dis os�1 Field: Distance from nea��est we ��___�Distafr'o�� Liquid depth__.'j� --------------Capacity___��..___ No. of com artmentJ____ _ Size p I f m4foundation___/e._......Distance to nearest to line-3:07.1__-. E ` � Number of lines___- '_ I g e� ------��------Width of french..-.......................... lf� �.__.�.___ -- --___ Length of each'�n + D`e th of filte ,m`ater+al__f "-______._Total len th___.,l, Q________________________ Type of filter material p g Seepage Pit: Distance to nearest well------------------- __Distance from foundation--------------------Distance to nearest lot line_____.__.___..... ❑ Number of pits--------1-----------Lining material-----------------------Size: Diameter-----------------------Depth-----------_---.----------------- I { r Cesspool: Distance from nearest well-------------_____Distance from foundation-------------------Lining material------------------------------------- F] Size: Diameter.11--------11 Depth--------------------------------- N-----------._Liquid Capacity--------- ------------------gals. Privy: Distance from neare`stt',well-_______________ ------------------ _------------Distance from-,nearest building-------------------------------.---------- . ❑ Distance to nearest 16f-line--------------------------------------- ----------------------- =--------------------------------------------------------------- rr s n Remodeling and/or repairing (describe):--------- -- -- ^�. .: :#------------------------•------•-------------`f••_.... \ -•-----•--------) ----••----------•----•----•-------- .a._,} / �: -------•------------•-•-------------------•--------------- .�... 1 i _ I hereby certify that 1 have.prepared this apjplicafion and that the work will be done in accordance with San Joaquin County ordinances, State laws and rules and egulations of'the San Joaquin Local Health District. ) , i [Signed) `� ----------- ` �vd}er Contractor) By:.- -- �- Title__ _ ' I - ---------------------------{ ) ---........-- ---- --------- (Plat plan, showing size of lot, location of syste relation to wells,'buildings,of e-b pleced on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY---i------- ------------------------------------------------------------------ DATE---1-,-`--r-'1-•`�Q_^---------------------------- REVIEWEDBY----------------------------------------------------------------- •-----------•-- DATE------------------------------------------------------------ BUILDING PERMIT ISSUED.---•-•...._t...........-%------------------------------------------------------------------------- DATE............................................................. Alterations and/or recommendations:------------------------------------------------ ---- ----------------------- •---•-•---•-...----•----- -•--••----------------- -•-•...._........................ r -------------•--- -------------------•------------- ------- ------ ---------------- -----------------------------•-------------------------------------------------------------------------------------- i •--------------------------------------------•--- ------------------------------------------------------------•------•------------ ------............I.... ----•--------------------------------------------------- I 1 FINAL INSPECTION BY:._L.... ------------------------------ Date------1-�'-..... ------------------------------------------ - - SAN JOA`QUIN10CAL�HEA'LTH DISTRICT r130 South American Street 300 West Oak S et 124 Sycamore Street 205 West 91h Street Stockton,California Lodi,California Manteca,California Tracy,California ES 9 REVISED B-59 ZM 5-62 ATLAS