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FOR OFFICE USE: ----------------------- ------ -------------------- I APPLICATION FOR SANITATION PERMIT Permit No. (Complete in Duplicate) f ---------- This Permit Expires 1 Year From Date Issued Date Issued .___.....7y4_3 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 AN LOCATION.-. ---19------ /` - * ••- � �� '�'' r Owner's Name------I ..... -------------------------------------------------------------------------------------- Phone...............•-•--•---------•--- Address------------ l ...._------------ &.-r �- ---7--------- ii;iv Contractor's Name--------------- ........ '--7r ------- ------------------------------------------------------- Phone................................... Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: __r__ Number of bedrooms __"_y____ Number of baths __/___ Lot size __...._____ _ __- _... .............. ------ Water Supply: Public system ❑ Community system ❑ Private Depth To Water Table -------- ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay d Adobe ❑ Hardpan ❑ Previous Application Made: {If yes,date-------------------1 No ❑ New Construction: Yes ❑ No ❑ FHA/VA: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic +ank 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 Field. Distance from nearest well_-,'d----__Distance from foundation...J-U..........Distance to nearest lot line__.....__._.. Number of lines_________z__________________ _ Length of each line________4_S_�`/______.Width of trench.____2.��___--._-._________ Type of filter material...lr.�i _____Depth of filter material....l�___ -------Total length........ -. Q---------------.------. Seepage Pit: Distance to nearest well_-------------------Distance from foundation.........----------.Distance to nearest lot line--------------- 11 Number of pits----------------------Lining material-----------------------Size: Diameter-----------------------Depth--------------------------------- 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----------------------------------------- 0 Distance to nearest lot line------------------------------ --- ---------------------------•-•-- ------------------------------------------------------------------------- Remodeling and/or repairing (describe):---------------- --------`--------�---------•-•-•------------_t--------------- ----•------•-----......----------------.---------- -' --- — /- - ----G-• - ---- --------------------------•------••------•----------------•-----.:.----------------•---»..---------------•_----------•-•------------•------------------•----------------------------------- 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 regulations of the San Joaquin Local Health District. a or (Signed)--------------�-:- — wrteriltd/or Contractor BY= n.�e -1` { ------ - - - (Title) (Plot plan, showing size of lot, location of system in relation o wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY - --------------------------------------------------------------•- DATE--/-Zk.l,?------------------------------------ REVIEWEDBY--------------------------------------------- ------------------------------- ----------------------------------- ------------ DATE------------------------------------------------------------ BUILDINGPERMIT ISSUED-----------------------------------------------------------------------. -------------- ------------ DATE--------•-•---•------------------------------------------- -- Alterationsand/or recommendations:------------------------- -----------------------•-------•-----••---------.......---------------------------...--------------------•------------------------- ------------------•------------------•--------------------------------------------------•------------------------_-----------------...----------------------------...-----••-----------------------...----------------------- ----------------------------------------- ------------------------------------------------ ----------------------------------------------------- --------------------------..---- -------------------------------- FINAL INSPECTION BY:-- ----------------------- Date_...---l--`� 40-- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 Wed Oak Street 124 Sycamore Street 205 West 9Th Street Stockton,California Lodi,California Manteca,California Tracy,California ES 9 REVISED 8-59 2M 5-62 ATLAS