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FOR OFFICE USE: A �l --------------------------------------------------------- APPLICATION FOR SANITATION PERMIT Permit No. -A' 7x-- --------------------------------------------------------- (Complete in Duplicate) Date Issued ......;.��.....�--3 ..__---------------------------------------------------- This Permit-Expires 1 Year From 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 LOCATION __ (/....._ . ....-'-. .r�!:= _...c Owner's Name---- yn..... --- *.I�.�r� - --- - ------- -------- -- •-- Phone_��.�.3:7.-s_S' Address------.... B •--------.....---------- -t `�-•-•----- Contractor's Name---------- ------ a - -"` Phone Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court [] Motel ❑ Other ❑ Number of living units: __ .._ Number of bedrooms _Number f baths _1.... Lot size _.... _ _ .off- . .............................. Water Supply: Public system .❑ Community system ❑ Private f�De;?Clay o Water Table .�U_ ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam Loam ❑ Clay ❑ Adobe❑ Hardpan ❑ Previous Application Made: Ilf yes,dote--------------------1 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.) Septic Tank: Distance from nearest well-----------------Distance from foundation--------------------Material....---..._........------___-----....._----.____. ❑ No. of compartments--------------------------Size.............------------------Liquid depth........ --------------Capacity----------•-------•--- Dispos ield: Distance from nearest well--- Distance from foundation-__-,/A........Distance to nearest lot line._5......... [!' Number of lines----------/------------------------Length of each line....26......... .........Width of trench.---_1;?�......................... Type of qaet�paqw I. Distancef lematerial Depth e to nearest well ___Q __D Distance frotmrf undatlon_._- ---�_.._Distance nttohnearest of line..-----.__-_ ❑ Number of pits-------�-------------Lining material._��---- -_.-----Size: D�ter.��---7f---Depth----,Y.-..--------------------- 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-------------------------------------------- ClDistance to nearest lot line--------------------------------------------------------------..............---•------------------------------------------------------------ Remodeling and/or repairing (describe):------- describe):....... ..... . ° . ---------- ------ --------------------------------------------------------------- `. -------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------•------------------------------- ------ 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 rule and regulatio s of +he San 6aquin Local Health District. G I r (Signed)-------------------- ---- ------ - - ---- -- --- ----- ------- wner an or a tractorl (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----- ---------------------------------------------------------- DATE_-.__...�' ----------------------------------- ----------------- . -- ---- ------ ---- REVIEWEDBY---------------------------------------------------------------------------------------- --- DATE------------------------- BUILDINGPERMIT ISSUED----------------------------------------------------------------------------------------------------- DATE------------------------------------------------------------ Alterations and/or recommendations:--------------------------------------------------------------------------- ........-•---------- -------------------------------------------------------------- --------------------------------- -- ---- ---- --------- -----------•---------- ----------------------------------------------------------------.....--••-------------------------------------------------------.....------ FINAL INSPECTION BY:--- �".-... . .-------•--------------- Date SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,California Manteca,California Tracy,California ES 9 REVISED B-59 2M 5-62 ATLAS �, 49