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FOR OFFICE IJSE : (2 h �_3--------------- - --------------------------------- ��__ ,I-:..--. APPLICATION FOR SANITATION PERMIT Permit No. ../ -------------- F (Complete in Duplicate) This Permit Expires 1 Year From Date Issued Date issued .... 3 i 1 _. 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..._----:_--------L---�1� ................�" rr't L - -�--------------- - ---- Owner's Name-------- G `` _1 ----- Phone._�_�L -- Address------------ `" � ` -` ... •`r Contractor's Name---------- - - - - -------------------------------------------------------- Phone....----......-- ........... Installation will serve: Residence 9_1partment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: -�-__- Number of bedrooms`:-- Number of baths pp :_--. _.__-_-------.- g l--..-. Lot sae / Water Supply: Public system P-IC;ommunity system ❑ Private ❑ Depth To Water Table ........ ft. Character of soil to a depth of 3 feet:I Sand ❑ Gravel O--Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe Hardpan ❑ Previous Application Made: (If yes,date--------------------) No ❑ New Construction: Yes, No ❑ FHA/VA. Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) W Septic T8, : Distance from nearest well_-71.9!!"'.-�'$rstance from foundation-_-_ -----.Material -'If. 1 No. of compartments----- f "i. 7K-:1`X.�. : _Li uid de th--------� a acttY Disposal Feld: Distance from nearest well--Ile __-f-_D sf nce from foundatio ....Distance to nearest lot line_-. ........ I Number of lines--------------- --- Leng o each line--------- --_Gf -f]__-..Width of trench----_Z _-------.___.... Type of filter material._._ �n��_�__-Depth o filter material__-c/�.---/._--Total length-----------� ................. Seepage Pit: Distance to nearest well---._' istance from foundation-----C-P-------Distance to nearest lot line:------------- Number of pits------:--�•,--____---Lining material-_!.&.�4.. ----Size: Diameter___7_�-------------Depth-----3�[`._------------- Cesspool: Distance from nearest well-----------------Distance from foundation.-------------------Lining material--------............................. ❑ Size: Diameter------ -------------------------- Depth --!------------------------------------------------Liquid Capacity--------------------_-----gals. Privy: Distance from nearest well---_-----_-----------------`---------------------Distance from nearest building------------__---__-_ 1. ❑ Distance to nearest lot line-------------------- - - - - I ------------------- ------- ......... •----•----------••-------------------•---------------- i Remodelingand/or repairing (describe)------------------------------------------ .................. -----------------------------------------------------------•---------•............ -••---------••----•---------------- -----------•---•----------------------•------------------------------- -----_-----------••------------•------------------------------------- ------------------------------------- ----------------------•---••----•---------------------------------•-•----------------------------- ----•--_--•-•----- -----------------•------------••------------------------------------------------------------------- {= 1 { -•----------------------------------------•---------------- ----------------•-- --------=---- --------------••------..---------- ---------•-----------------------••----------- I hereby certify that I have prepared this application a"nd that the work will be done in accordance with San Joaquin County ordinances, State laws and rules and a ulations of the San Joaq uin Local Health District. Si ned h-��►'f A _ -----------------------i ----------------------------------- --- Owner and/or Contractor I ------------------------------------------------------I--------------- tTitle---------- --------------------------------------------------- (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 APPLICATION ACCEPTED BY------ l'ee'r-. - �T. DATEf�I- ' -- Y _�.��-�-------- ---------------------•---•----.._ REVIEWED BY-------------------------------------------------------------- -�-='-�-i... DATE---•----••--------------• BUILDING PERMIT ISSUED.. ---------------------------- ----------- DATE-----------------•--�=--------------------------------- AFFeratians and/or recommendations ..___---- •_------ -- 1 � �^^ ------------ -------------------- ----------------- ._.-G--- e%� -_ _:- --------• ---- --- --- - - ---------- .Z.-< .�` L---- --------- --` z �-12 11 - . � ----- ---. -- - --- -.-. . C�- -------------------------`-- v- ---- -_- - -- -_------ ----------- -`---- -- FINAL INSPECTION BY:......... 1 /ti � -------- Date --- -- ' = , ��C I SAN JOAQUIN LOCAL HEALTH DISTRICT " 130 South American Street 300 West Oak Street I i4 Sycamore Street 205 west 91h Street Stockton,California Lodi,California Mantecfi,California Tracy,California ES 9 REVISED 8.59 ZNI 5-6Z ATLAS ' A