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FOROFFE�EIUS-------- ....._.._.__. ....... --------------------- APPLICATION FOR SANITATION PERMIT Permit No. ...�,1-_ �!- ii (Complete in Duplicate) /v Date Issued II This Permit Expires 1 Year From Date Issued .... ..........6__7� 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....- ,off''----- �--••--- = ------ - --- - ---- ---------------------------------------------- - Owner's Name............../�-..il ....... ---------------------- -------------_ Phone.................--................. _D Address. -_. .- -- ---- ---- ----- ------------------------------------------•-••••••--•-•-•--•--•-------•--•----•-----• Contractor's Name=-------------------------- -- ---- - -------- ......•---------- ..-__-------- --------•------ Phone.............................------ Installation will serve: ',Residence Uj-�pa rtment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑j Number of living units:�,___I Number of bedrooms .- Number of baths 1.... Lot size _ �.._.�_.�............�___------.._ ,Vater Supply: Public'systemll.[ Community system ❑ Private ❑ Depth to Water Table. ft, r Character of soil toe depth of 3 feet: Sand ❑ Gravel ❑ Sand Loam ❑ Clay Loam ❑ Clay ❑ Adobe Hardpan ❑ Previous Application Made: (If yes,date.------- ---..) No New Construction: Yes �❑ FHA/VA: Yes L ,- No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) d � �- Septic T k: Distance from nearest wail..........-----..Distance from-foundation_.Z -------- al.....C.?..�:..._._........__�.......... ..... No. of cornpartmen#s---------✓----------Size,--- 42------Liquid deptFi.._...Y,ca----------Capacity.... ........ Disposal N ld: Distance from-nearest well.-_!7" .__..-Distance from foundation.../d .......Distance to nearest lot line._- ......... Number of lines............:..... Length-of each line..........--------- Width of trench.--_�.Y_!..............._.. Type of filter material._-_.--- ar-Jeepth of filter-material--- --------Total length-_/V.1 ---_______._._-----. SeepageDistance to nearestell--------- -----------Distance from foundation__ .-'d.. _ _-•-__..Dista�e to nearest lot lint;c�_....__--- Number of pits------- --------Lining material---- _ .l ...Size: Diameter �i -j_...._.......Depth-_;;Z�4,t'................ . t, i Cesspool: Distance from nearest well_..•............Distance from foundation....................Lining material__.....-....-..._._..................El \ i Size: Diameter--------------------------------------Deth------------------- --------------Liquid Capacity ---gals. Q Privy: Distance from,nearest,well--------------------------------------- -------Distance from nearest building------------------------------------.--- - ❑ Dis4nce_to.-nearest-lot_line-------------------------_--- : Remodeling and/or repairing l'(d --- escribe : ----------- - :"': ... ... --_-_- lCC rC ...................................... -•----------•----•---•---------•------------•------•---------•-••-•--------------i ••-------------- it ...........I—------------------------- ----------------------------- ---••-----------------------��---•-•-----••------•-----...---------------------------------------•--------------•--:------•---•----------------------------...---------------------------••------- --------------•------------------•-- -•----------------=----------------------------------------------------------------------------------------------------------------------------------- ------------------- .4; hereby certify that I have prepared-this-applicatioti enc!"-that the work will'i`e done in accordance with San Joaquin County ordinances, State la s, and rules and regulations of the San Joa 'n Local Health Distric+. ✓ f (Signed) :CJ -- ------(Owner and/or Contractor) By:------_-----_-------------- 2. lf�_--- - -- � -- ---------------(Title}--- .. ... - • -- -- ----------------- I (Piot plan, showing size o ,ilocation of system in relation to wells, buiTatmgs, etc., can be placed on reverse side). ' 11 FOR DEPARTMENT USE ONLY.- l APPLICATION ACCEPTED BY.. .- ------------------------------------•--- DATE--- .... REVIEWED BY_........... ��-l ---------- ----•---------------------------------------- DATE . :. BUILDING PERMIT ISSUED---'I ------------------------------------------------------------------------------------- DATE------------------------------------------------- Alterations and/or recommendation :._ .--- `:_._ ..-------- -- ---------------------------------------------I...... ----- ......................•--------------------------------------------------------------------------------------------------------------------------- II�.. t . - -------------------------------------------------------------------------- ------- --'--------------------- ----------------------------------........-----------.--------------------------------•. . ......---......--------------------------------------- --- •_lNSPET0N Da#e_ FINAL ': - -- --------- SFAN�JOAQUIN`LOCAL HEALTH DISTRICT 130 South American Strut �i 300 Wast Oak Street 134 Sycamore Street 205 West 91h Street ; Stockton,California i Lodi,California Manteca,California Tracy,California - ES 9 REVISED 5-59 PM 5-61 ATLAS �I it ��