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FOR OFFICE USE: --- ------- - �oil Permit No. .. ... _. C - - -4 APPLICATION FOR SANITATION PERMIT - ----------------------------------- /xx --------------------------------------------------------- (Complete in Duplicate) Date Issued ---�I�---fs�l ------------------ ---_.....___............. This Permit Expires ll Year From Date Issued L. --------- Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described. i This application is made in compliance with County Ordinance No. 549. r -------------------------- •---...... JOB ADDRESS AND LOCATION-- Cl Z---X-------------- Wit, Owner's Name-------••----- - Phone-1` -----•--•----------•-- Address----------•-------------------------- �,y�_' -'-'- Phone. .... Contractor's Name------•---•-•------------------ •-• -•--•- Installation will serve: Residence 0 Apartment:House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: ../..___ Number of bedrooms ._, . Number of baths ----/__ Lot size ,._.s'*`_Q-- - •••---------•-•------------•-•- ' Water Supply: Public system Community system ❑ Private ❑ Depth To Water Table/ +. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam [X Clay ❑ Adobe [3 Hardpan ❑ ' p Previous Application Made: (If yes,date--------------------) No New Construction: Yes ❑ No [ FHA/VA: Yes E] No [' TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if,public sewer is available within 200 feet.) , Septi Tank: Distance from nearest well_________________Distance from foundation....................Mate rial------------------------------------------------- __:'_=....--Capacity / ycompartments..---------•-----------•--Size Liquid depth------------ P tY Asp { ield: Distance from nearest well...... Distance from foundation,-..................Distance to nearest lot line----------------- aT" - . ? Ynber of lines-----------------------------------Length of each line--------- Width of trench pe of filter material-------------------------Depth of filter material----•-----------------Total i length------------•_-------------_-_-�-.-.-_-Q-•_-.-.•.• earest well______-r ----Distance fro foundation_...__..___.Distance to nearest lot line.... ¢e: Diameter_See a e it; Dis 'ng material _ - Depth--------12--Z--f------- tsNumber of i� '" 0. = ---•--Distance from foundstion--------------------Lining material--------•------•-----. .-------••--- \ mrarest lel ool: DistanCessp `s 'd Caaci ----.gals. Size: DiameeDep er ❑ :build ng. .. Privy: Distance frim nearest wel- .- -Distance ❑ Distance to nearest lot line----- ------•-----------------------��'-`'=•'��-.Y..w.......-�,;��."--------------o "'-------_-----••- -----•--------- --- . Remodeling and/or repairing (describe):------ ------- �� - .^lt /l��_^Ij I � / - I hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State laws, and rules and regulations of the San Joaquin Local Health District. �y �------ -------------------------------------------------------- (Owner and/or Contractor) (Signed)___.. "�- - , `��f�� lBy-------------- -1------•--------------------------------- ---------------------------------------- ------•----------------(Title)---------- ----------------------------- -------- ------------ (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). FON DEPARTMENT USE ONLY APPLICATION ACCEPTED BY----. - r ----- DATE--------- �, REVIEWEDBY----------• ----------------- ---- ----------------------- - DATE.............---..----------------••--••-------------------- BUILDINGPERMIT ISSUED.......... ---------- - --- --------------------------- ----------------- DATE--------------•----------=---------•------------------------ Alterations and/or recommendations:----------------------------------------- ----------------------------------------- -------.--------•--- ----- •--.1--------------------- G a��-� - -- - -- FINALINSPECTION BY------------------ ------------------- -------------------------- Date----------------------------------- ----------------- -----------------•- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Srreet 124 Sycamore Street 295 West 9Th Street Stockton,California Lodi,California Manteca,California Tracy,California E5 9 REVI5Eri 8-59 2M 5-62 ATLAS ,, .• �