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FOR OFFI E SE: ----------�-- 3 ------------------ - --------------------- ------- -APPLICATION FOR SANITATION PERMIT Permit No. --- I ----------------- ---- --------------------- ----•- --- Complete in Duplicate) Date Issued ------------ This This Permit Expires 1 Year From Date Issued Application is hereby made to the San Joaquin Local�Healfh District for a permit to construct and install the work herein described. This application is made in compliance with County OIrdinance No 549. JOB ADDRESS AND LOCATION----------- /--.--- -•----•..... - --------- -•-•-•••-•-'e�. �"Q'----------•--•------....-•------------------•-••-•-• '41 ,�:.�.l._7.1_..... Owner's Name----------- --- -- - --t--• 1-------•�- - ----- --------------------------•----•----- Phone-�-- Address--------------- ! -•-•-------- -------------- ------ ---- 0_... ••--•----- --- ---------------------------------------------Phone./-•------•---••-•••-•-=-•--••------... Contractors Name----------------_- .. ..---......... .. II ----------. -4 ... •--••--- �C? �l�G r� Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑/Motel ❑ Other ❑ Number of living units: -------- Number of bedroJlopms ._Number of baths ---I--- Lot size ---- ---------------------- Water Supply: Public system M Community system ❑ Private ❑ Depth to Water Table -------- ft. Character of soil to a depth of 3 feet: Sand ❑ Grlavel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobeo Hardpan ❑ Previous Application Made: (If yes,date--------------------i] No ,9 New Construction: Yes ❑ No p) FHA/VA: Yes ❑ No IN 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................................................. ❑JXis�l No. of compartments--------------------I��....Size---------...---•------------•---Liquid depth--------------------------Capacity....................... Disposal Field: Distance from nearest well-_/SID :Distance from foundation-_ o Distance to nearest lot line.g-7...... �f Number of lines..... .. ----------- !i ---.______��.___Length of each line____�_�r_._______ Width of trench___.�_4:...................... Type of filter matenal.�. _� -.-.Depth of filter material_._J_ ____________Total length------ - _.-----------------_....... Seepage Pit: Distance to nearest well__ � `__Distance from foundation_ .-......Dista)lrce to nearest lot line„ �._____ Number.of pits___B'1'I�_C_J_Lining material.Rnej�------Size: Diameter__._�3__.---------Depth-_.',�, ___________________ Cesspool: Distance from nearest well----------1_.'.Distance from foundation--------------------Lining material-___-.:-___--__-_-_____-:_-__________ ❑ Size: Diameter------------------------------- .....Depth--- ------------------------------------------------Liquid Capacity._'........................ Priv D'1+ tance from nearst well se ---.__.___1I�'- Privy: f I _ •- --Y_____-___ __-___--Distance from nearest building-----------------_- ❑ Distance to nearesf%t line----------�!---_-.-__ Remodeling and/or repairing (describe):--- � / E-------------- -----' ---•-•--------•-----------•---- .--•----•--•-•-------•---......I---••------------••----- ............. -C�1_ _ . .I ....p.r--.--- •------ .------------------------------------------------•---------•--- •-----•---•------------------------------- ---------------------------------------- ---•------- �g� •------•-------•-•---- ----------- .4......� ---.l----------- ---- ---------------•----------------------------------------------------------------..-------'.....-------.....---....--•------------- ! hereby certify that I have r aced this application and that the work will be done in accordance with San Joaquin County ordinances, State laws, and ru s a regulations the San Joaquin'Local Health District. (Signed) --------------------------------Owner and/or Contractor By:........................................---------------- li -:------ --`'�- ---fri le)-------/on .------------------ --------------t(Plot plan, showing size. of lot, location of system in relation to wells, buildings, etc., can be placereverse side). FOIA DEPARTMENT USE ONLY as APPLICATION ACCEPTED BY-- �.__iI _ ,.�.r�/ --------------------- DATE-------- �--•--•---•---- REVIEWEDBY...............-------------- --- ---------------------------- ----------------------------•------------ ------------------ DATE------------------------------------------------------------ BUILDING PERMIT ISSUED..... !IN. ........ --------------------------•--k--------•-- DATE---------------------------------------------- •------------- Alterations and/or recommendations:.___ ____ _ _-Ge_ _.-__j __G_ - -...... 10�u� .. � -•----------------------------=--------------------------------------------------------- -------------------•-------- .................---------- -------------------- ---------------------------------------------------- ------------------------------- ; i ----------------------•----•---•-.-....---- ------------ ----------------------------------------------= --•------------------ - i ---•-------------------------- ------• .... ............... ••...` III-------------------------••--------- --------- ------------------------------------------------------- ---•----------•--•--•------ FINAL INSPECTION BY:. ----•--------------- Date- -------------------------------------- -------------------------- SAN --------•----------SAN JOAQUIN LOCAL HEALTH DISTRICT 1 130 South American Street 300 West Oak STreet 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,California Manteca,California Tracy,California EE 9 REVISED 8•1119 gM a-61 ATLAS 1