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_— FUR fN USE: C� - ___-___ APPLICATION FOR SANITATION PERMIT Permit No. ..... .l..J~ --------------------- (Complete in Duplicate) l_ 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. JOB ADDRESS AND LOCAT ON...__ -- f Q 0 ,� je --------- -- - _----------•------------------ Owner's Name.___ .__. Address --------- ----------- -- Phone.,.................................. - -----------------------------------------------•--------- ------ ---------11.11------- ----••......----— Contractor's Name_____________ - -•------------- Phone Installation will serve: Residence ['Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: Number of --3-- Number of baths .1----- Lot size 1 Water Supply. Public s sem/�Communi system t � y tY Y ❑ Private ❑ Depth ro Water Table .4:a_ ft. Character of soil to a depth of 3 feet: $and ❑ Gravel ❑ S dy Loam ❑ Gay Loam ❑ Clay [] Adobe[Hardpan C]Previous Application Made: llf yes,date-------------------I No New Construction: Yes [j;'No ❑ FHA/VA: Yes ❑ No TYPE OF INSTALLATION AND SPECIFICATIONS: No�eptic tank or cesspool permitted if public sewer is available within 200 feet.) Sep c ank• Distance from nearest well_._____ _Distance from foundation--------------------Material ._..___._._ No. of compartments--------------------------Size-------•------•-•------•--------Liquid depth---•----------- ----------Capacity --------------•----1111 Disp Fi Distance from nearest well-----------------Distance from foundation---------_-----____.Distance to nearest lot line... ____._.__..... Number of lines--- -------------------------Length of each line-----•--------•--------••-----Width of trench -- Type of filter material-------------------------Depth of filter material-----------------------Total length-••-----•------_-----__-••---..../----- Seeps Pit: Distance to nearest welL_�" �--- Distanc� f undation_ -0--_- _-_- Cess Cesspool: Number of pits___{_ ---------------Lining material_____/--__ (47----Size: Diameter--Z?--'r'tace toDne�thst lot i S p : Distance from nearest well_________________Distance from foundation-------------------- material__-______,1_______1.1____1-__ . . __ - El Size: Diameter. 5---------- --•----------------Depth----------------------•------ -------- -----•-Li Liquid Capacity - - - q - ----...----•--------------gals. Privy: Distance from nearest well -----------------------_---------Distance from nearest building ❑ Distance to nearest lot line------ ------------------------_____________________________ Remodeling and/or repairing (describe)------------------ ••-------------------•-----------.--- - ---------------------•-------------------•-----------------•--••------ I hereby certify that I have prepared this applicat' and hat the work will be done in accordance with Sen .Joaquin County � ordinances, State laws, and rules and `regulations of San oaquin L al Health District. (Signed) ----------------------- -- ------ - {Owner and/or Contractor) ----- By: (Title)- ------------------ (Plot plan, showing size of lot, location of system in relation to wet , buildings, etc., can be placed on reverse side). FOR DEPAATMENT USE ONLY APPLICATION ACCEPTED BY. ---------------------• --- DATE---- d-l.�=�P _ REVIEWED BY-------------- —7---- ---- BUILDING PERMIT ISSUED ------------ ----------• ............................................. D TI:_. ------------- Alterations and/or recommendations:--- �' x-S'--�-z� / `� -------••--------•--•------•- ,,/� r c:`.._.. --------r----------------------- -- -----------••----------...--------1111 -•--- .............................. -----.. J -- -------------- -----------------•----•--•--------- - -- r FINAL INSPECTION BY., W 7 - � Date ----- -= SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street i 300 West Oak Street 144 Sycamore Street 205 West 9th Street Stockton,California t Lodi,[aii}ornia Manteca,California Tracy,California E5 4 REVlSE� 8-59 2M 5-b� ATLAS -