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- R OI U E: .._` L r2 � r APPLICATION FOR SANITATION PERMIT Permit No. . -(fit.............� -------------------------------------------------------- (Complete in Duplicate) Date issued -----------------_-------_---------_--------------------- This Permit Expires 1 Year From Date Issued Application is hereby made to the San Joaquin Local Health District for a permit to construc�an9 install he work herein described. This application is made in compliance with County Ordinance No. 549. �� aurru.l JO ADDRESS AND LOCATI N ' r -------------••------•--•------•----•- ----------•-•------------ Owner's Name •- l�hr1�._f l � ------------------- Phon ---- Z `�i'•a 1 - ---Address------------- -- --------------- Contractor`s Name_ 011- m - --- --------------------------------- Phonlv .......... mer Installation will serve: Residence Cpartment House ❑ Cf r [❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: j----- Number of bedrooms .21- Number of baths I... Lot size ----- -------- _e. a ------------- t Water Supply: Public system ❑ Community system ❑ Private [:] Depth To Water Table 6.. ft. ' Character of soil to a depth of 3 feet: Sand ❑ Gravel [] Sandy Loam ❑ Clay Loam ❑ Clay ❑ dHar obe dpan ❑ Previous Application Made: {If yes,date--------------------) No El New Construction: Yes ❑ No FHA/VA: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: t (No septic tank or cesspool permitted if public sewer is available within 200 feet.) s S c_J -�"' Distance from netarest well_________________Distance from foundation--------------------Material_____________._._____________-•--____-_-_-_-----. p� ,•� No. of compartments---------------------�-Size--------------------------------Liquid de�--------------------------Capacity---------------�-------�--- Dls sal Distance from nearest well__0.___._Distance from foundation---4Q........Distance to nearest lot line__.__I�._ Number of lines'_______._ . _ Length of each line_�_12_ `___�f..Width of trench.__ ._ '.'__ - � Type of filter materia._ {Depth of filter material_______ __ g Q Total length-- ------------- Distance - Se Distance to neare$t well_r- _l9_�_____--Distance�om froundation__ a__ _.Distance to nearest lot line Lam�46 Number of pits----r-----------------Lining material.-•---- p--�-�-- -----Size: Diameter---��•�---Depth- ....... Cesspzolc -+r Distance from nearest well-----------------Distance from ff ndation-- .--------------Lining material------------------------------------- Size: ._-_.________.___________________ _Size: Diameter--------------------------------------Depth----------------------------- ------ ---------------Liquid Capacity----------------------------gals. Privy: Distance from nearest well-------------------------------------------------Distance from nearest building____________________________._______--___. ❑ Distance to nearest lot line------------------------------------------------•------------------------------------------------------•--•--•------------•--•-------•-------. I Remodelingand/or repairing (describe)---------------- ---------- - -------------------------------------------------- ------:-----------------------------•-----•------------------ 1 -----------•-------------------_-_-----•-------•----------------••- ------•------ ----•------------• -•----..._... ----- •---------••-----------------------•---------------- -----------------•-------------.---------•-------------•-•---f-•------ r' { �_.l -------------------------------- ----------- -------------- hereby certify that I ave prepared this application and that the work will edone in accordance with San Joaquin County ordinances, St S.00do rules and auI tions of the San J quin Local Health District (Signed)- *a- !'�'-' (11 I�Contractor] By:----------------------------- --- .. - -•-•- --•• -` - ---- - --- --------- -(Title)--------------------------------------- - - ---------------- (Plot plan, showing size of lot, location of system in re to wells, buildin etc., c be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY---- '---------------------------------------------•---------------- DATE---------- ------ 1�- --------------------- REVIEWED - .REVIEWED BY------------------------------------------------------------------ ------------------------------------------------.......... DATE----------------•-••-----------------•------•------••• BUILDING PERMIT ISSUED-----•------••-----•----------------- -•------------------------------------ DA- E--------------.. r-------.fJ .-- .- ..------ ------ --------�1C�•--•- Alterations and/or recommend'ations._•.-�- ---•�--------------- --------------------- -1--------------------------------------------------------------------------- -----------••----- ----- ------•------------------------•-----------•---------•-----••--•-----------------------------•---- -------------••-...---- -------............-.--------------------------------------- ---•--------•-------------------------------------------------------------------- ----•------------------- ---•----------------------- ------------------------------------------------------------------------- ------------------------------------------------------------------------- -----------------------------------------------------------•_1------ ------------------------------------------------------------------------- FINAL INSPECTION BY:.......... ,..e� _____ Date__.____.._.�___f�� � �1 - ------------------------------------------ SAN JOAQUIN LOCAL. HEALTH DISTRICT 130 South American Street 300 West Oak Syreet 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,California Manteca,California Tracy,California E5 9 REVISED 8.59 2M 5-62 ATLAS