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FOR OFFICE USE: --------------------------------------------------------- ------------------------- ------------------------------- APPLICATION FOR SANITATION PERMIT Permit No. ----------------------------------------------------- -- / (Complete in Duplicate) Date Issued 2 -------------------- This Permit Expires 1 Year From Date Issued_ ,I Application is hereby made to the San Joaquin Local Heal♦h District for a permit to construct and install the work herein described. This application is made in compliance with County Ordinance No. 549. JOS ADDRESS AND LOCATION---,oz2!�......O-�-J�-A{ _xe.. - e 6�' Owner's Name-- ____-- -- Phone------------------------ - Address------- ... ...---- ------------------------------------------"•---•----•---•----•----------- y / Contractors Name. --•-•- -- -- •------ �ls .l Phone_'f`if_J:., Q. . Installation will serve: Residence Apartment Ouse ❑ Commbrcial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: .1----- Number of bedrooms A__ Number of baths __I___ Lot size --------___________ Water Supply: Public system (V Community system ❑ Private ❑ Depth ro Water Table -------- ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe,,N Hardpan ❑ Previous Application Made: (If yes,date--------------------) No a New Construction: Yes ❑ No 9Q 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....................... Disposal Field: Distance from nearest well-____-_-_____._Distance from foundation....................Distance to nearest lot line.............. Number of lines-----------------------------------Length of each line------------------------------Width of trench-------------------•--- Type of filter material--_--------------------Depth of filter material------------------ �'otal length------------_----------- ----_----.------_- r �, Seepage Pit: Distance to nearest well--- _-_____Distance from ound -. ation___. .......___.Distance to nearest lot line_________________ (d Number of pits._.___�----------Lining material---56 _.._-.-Size: Diameter____T.T`/---------Depth---,__ _•_____--;_____ Cesspool: Distance from nearest well_________________Distance from foundation--------------------Lining material-------------------------------------- 0 Size: Diameter--------------------------------------Depth-----------•--- ------------------------------------Liquid Capacity------•-•------------------ga Privy: Distance from nearest well-------------------------------------------------Distance from nearest building______.____:_______--_•-••-____---____._. ❑ Distance to nearest lot line------------------------------------------------ ------------------................................-------- --•---•----------------------- Remodeling and/or repairing _! - _ ...............------------------------------------------------------------------ --------------•--------------------••-----------•---•---•-----------•------------•------------- ------- --- -----------------•--------•----------------•--------•------------•-------••--------------------------------------------------------•------•-------.......----•------------•---••----------....------------------------------ -----------------------------------------------------•-----•------------•-------------------------------------------------------------------------------------------------------------------------_-------------------------- 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. (Signed) ----- -- --- - ------------------------------------------------------Owner and/or Contractor BY:-/_') ' !r ----------------------- ..._(Title) (Plot plan, showing�S_-, fcatio orsof�sys� min relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY - -• - --•- --------------------------------------- DATE---cP--__tA.= -67--------------- •------------ REVIEWEDBY-------------------- _________`-'._._..-------------------------------------- DATE-----------------...----------------••-•-------------------- BUILDING PERMIT ISSUED----------------------------------------------------------------------------_...---•--•--•--.._..... DATE------.-------------------------------------------------- Alterations ------------•-----•---- ----- ...._....Alterations and/or recommendations:------------------ -------------- ------------------------------------------------.--------------------------•--•------------------------------- .......------ -----------------------------------------------------------------------------------------------------------------------------------------•-----------------------------------------------------=------------------------------ ......... . .... ..... - -------------------- --------------------- ----- ; FINAL INSPECTION BY:..... _ Date---j----.�1.-..6_:7_. -------- -------------------------------- SAN'JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 124 Sycamore Street 205 West 91h Street Stockton,California Lodi,California Manteca,California Ttacy,California ES 9 REVISED a-59 2M 5-62 ATLAS i