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rc�xc.�rrlc,t u5t: --------------- - - - - - --- APPLICATION FOR SANITATION PERMIT Permit No, -------------------------------------------------------- (Complete in Duplicate) S 7/ ------------- 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. _-L,55--2,3, - eQ? JOB ADDRESS A LOCATION_+:- --------------------- A ....................j....... Owner's Name...-..r1Gr` s. ----- •-------•------•-- - .. ------------- Phone.................................... ! Address--------4_21--F *' ..Ago----------- ------ . ................•......................... - Contractor's Name ----------- ------------------------------------------------ Phone............................... will serve: Residenc �artment House Commercial Trailer Court Motel Other p ❑ ❑ ❑ ❑ Number of living units: __- _-_ Number of bedroom's _Number of baths'�� Lot size ...._111.2---- !c ^�. ............. Water Supply: Public system ❑—Cammuriity system ❑ PrivateDepth to Water Table ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay X Adobe❑ Hardpan ❑ Previous Application Made. (If yes,date--------------------) ,No14•�.,New Construction: Yes No ❑ FHA/VA: Yes ❑ N091 TYPE OF INSTALLATION AND SPECIFICATIONS: [ t ° (No septic tank or cesspool perrrlittedI.if public r w er is available within 200 feet.) s SFptic Tank: Distance from nearest wellffl--.�___-iDistance from foundg�ion_--)..)............M t 181----- ....�i� 3 .................. .... . s - , o '1 No. of compartments-y-_}-------------Size. ?. _- _.�.7:___Liquid de;?th_---.____ -.-.` --Ca . Disposal Field: Distance from nearest well-ISO-0-------Distance from foundation '•__ ^_....Distance to nearest lot line_-,... Number of lines__ . Length of each line-_--_- -. ----.Width'of'trench--_-_Z. .�--------------- Type ............. T e of filter material.�._ _ yp _Depth of filter'material---- -----_--Total length- --- __-��-_ --_-_.--.- Seepage Pit: Distance to nearest well----------------------Distance from foundation....................Distance to.nearest lot line----------------- Cl Number'of pits----------------------Lining material---- .........-------Size: Diameter---------------........Depth-----............-._------------. Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material=----__------------___-__._-.-._ ~ ❑ Size:.,Diarneter--------------------------------------Depth----------------------------------------------------Liquid Capacity----------------------------gals . -� Dist rete from nearest� W ----------------------- Privy: � 4^ �� - Distance from nears � � �-� earest wellst buildiri ---- g-------- ❑ Distance to nearest lot line----------------------------------- ---------------------•-----•-------•------------------•- ---•--------- .---------- ---- 1 A � Remodel' d/or pairiri describe): i ... .............. - -.._-.. . i -----•-----------------------------------------------------------------------•---•---••--•-•-••------------ ..---- ---- ---------------------- ------------------•----------------------------------------•-•---------------------•-------------------=------------------------------------------------------------------------------------------------------------------- -----=a---- 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 r,gula-'ons of the San Joaquin Local Health District. a (Signed). ....... o `------------------ ------ ----•------•------- ---------------•--•---•----...---------------.-{Owner and/or Contractorl Br (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 �- , r � = -. �► i _ N APPLICATION ACCEPTED BY----------------------------------- --------------------------------------------------------- DATE------------------------------------------ - REVIEWED BY------------- ---------- ------- ---------------------- DATE-•----------/-p-- BUILDING PERMIT ISSUED---------------------------------------- ---- ---- -..-----.--.._...----- DATE Alterationsand/or recommendations------------------- -- --------------------------------•--••-----...-.-•---•-•--------.-.-----.-..------••---------------••-•----------------------•-•------.. -•---•-••----------------------•---.-...-----------•-------------------------------------•----•-------------------•-----------------------------------------------------------•-••----------•-••------------.----•--•-•----... -------........----•---------------------•--------•---•---------------------------------•--------------------------------------------------••-•--------------------------------•---------------•---......•-•------------------- •-•-------•--...-•------------ ------------------------------------------•---------------•-------------- --•------------------• -•-----------------------------------------------...----------•--•---•---------------- 6FINAL INSPECTION BY:--- ..._._�_� --------------- Date----------(� ---------------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 124 Sycamore Street 205 Went 91h Street Stockton,California Lodi,California Manteca,California Tracy,California EB 9 REVISED B-59 2M 5-81 ATLAS c s