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FOR OFF%YSE: _r1f_1'gr 7 6 � 3 I I 16ze' .Y� -3 APPLICATION FOR SANITATION PERMIT Permit No. .._1.7-/-z------------------ ----------- ---------------------- --------------------- (Complete in Duplicate) ........... This Permit Expires I 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 oy'nfy OrdinartNo. 549. JOB ADDRESS AND LOCATIO ......... ........... Owner's Name--------------- ....... ............ ------------------------------------------------- Address ....................................................................... ............. ----------- 1------------ I . r .. _......... Phone----------------_------------ Contractor's Name....... `-••-----....._.•---------------- ............................................................. InstallaMor will serve: Residence Apartment House 0 Commercial [3 Trailer Court [3 Motel,[] Othbf Z.-:- Lo -------- Number of living units: Zn.,Nut;nber of:bedrooms ... Number of baths f,size - ---- Water Supply: Public system El Community system 0 'Rrivafe,g Depth to Water Table Zm& ft. Character of soil to a depth of 3 feef-- Sand El Gravel E] Sandy Loam Ig Clay Loam E] Clay 0 Adobe 0 HWpan 0 Previous Application Made; (if yes,date....-.. No ra New Construction: Yes E] No [;N FHA/VA: Yes C1 No [Z TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tank: --,Distance frorrr.nearest Distance from fotindation.......Ze_x......Material...... 0 N6.,of corn gifments....i------z;-------size----- depfh-----y..I--------------Capacity....... Disposal Field.,- Distance from nearest well--. Distance from foundation.._- -----Distance to nearest lot line...... Number of lines----_____- 77�f_--Length of each line............<OF ___._....Width of trench..........ax.................. Type-of filter materialA filter material---,oV. ----- Total length-----------go...9"........... .... Seepage Pit: Distance to nearest we.11"--------------------Distance,from,foundation....................Distance to nearest lot cine...._ .......... 171 Number of pits.......................Ljning'mater!61�..`-----------------.Size: Diameter........................Depth---------- ...................... L il . Cesspool: Distance from nearest well------- ........Dist.anc0rom foundation--------------------Lining material....--......--............__.._...... Size: Diameter------------------------------------------I........Depth.-..._..------.---------------------------------_..Li uid Capacity----------.................gals. D - - T. I ...... ------- ---------------------------_----------_ Privy: Distance from nearest well--- ------------------------- Distance from nearest building ❑ Distance to nearest ]of line----------------------------_-}. ----------------....... -------------------_-................... ................. ---- ...... Remodeling ;ndy/ r repairing (describe):----__.---5- ----- e ............... -------- ........_... f ........... .----•------•-------------•---------•----•-•-------........................--------------------------- ...........1-••---- ----•-----•--------- ------------------------------ -------------- ---------------- ------------------------------------------------------------...................................I------------- --------- ------*_I`__h__e_r__e__b---y---c e--!r--f-if- t ha--f---I-_h,-a'veprep-a--r-e"d-i'h'i's---a-p...p'lication and that the work will be done in accordance with San Joaquin County ordinances, State laws, aAd rules and regulations of the San Joaquin Local Health District. (Signed)-- --- ---- ---------- ----- ----- ------------ ---••-----------------------------------=----•-•---------------- .....(Owner and/or Contractor) ti By:---------- -------------- -----------------------------------------------------_------------------------- _-_-------------------- --------M414-------------------------------------------- (Plot plan, showing size of lot, location of system in relation to wells,..buildings, etc., can be placed on reverse side). FOR DEPA�RTMENT USE ONLY I----------- DAT Ilk-- --------------- ---------------------- E-------- _6. APPLICATION ACCEPTED BY---- ..........., --- � / I I % , --- ------- ---- DATE----------------------------------------- REVIEWED BY---------------------------------------------------- --------------------------- -------7------------ .... BUILDINGPERMIT ISSUED---_------------------------------------------------------......... ----------------------........ DAT&------------------------------------------------------- t Alterations a9*/or rqcommendetions:--------------- ---------------------- .................................i-------I..................... ..... ............ ... --------- ---------- • 7� ..... ---------I................................................. IlF --------------------- . .... ---- --------- --------�e. .....�j - / ---------------------------- ...............1.................................. ................ -- -------------------- ------------------------ -----------------------------------------------......... ------------------------------------------------------------------ ----------------------------------------- ----------•--,------ ---------------------------_ --------------_--- ------------ FINAL INSPECTION BY:. ... .....................47------------------------- Date....--:. ------------------------------------ SAN JOAQUIN LOCAL HEALTH`DISTRICT 130 South American Street 300 West Oak Street 124 Sycamore Sir*@# 205 West 911%Street Stockton,California Lodi,California Manteca,California Tracy,California Efi 9 REVISED S-59 EM 3-61 ATLAS