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,� FO FFICE U ��----- ef -- -�------ + Permit No. ... _ APPLICATION FOR SANITATION PERMIT ` ---------- y- --� -----------------------3 4 (Complete in Duplicate) --. 1---- Date Issued .--•- -- .----_--_.---.- _"_ This Permit Expires 1 Year From Date Issued / (-0Q0— C,c� Application is hereby made to the San Joaquin Local Health District for a permit to construct and install t a wor i rgei ascribed. This application is made in compliance with County Ordinance No. 549. c(2-OS'l S'• t�-r S��--�2•e� � r JOB ADDRESS AND LPC ION-•- -- -- -----------/ =<:..._ ... --. � Owners Name--K ' ----•• -r----- Phone-._............................... i Address-------- - ----- .. .----••--��--��'- - ---�---- - 2- --- - -- -----•--------------- -----...----•---••--••. •----- Contractor's Name. Phone Installation will serve: Residence U?"'Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ - '" Number of living units: ..__- Number of bedrooms_f__ Number of baths J--- Lot size -e- -------------------------------------- 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 ❑ Adobe Q-"Aardpan C Previous Application Made: (If yes,date-------------- -) No New Construction: Yes gjel�o ❑ FHA/VA: Yes Zllgo ❑ "�, ' TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tank: Distance from nearest wet _St.�-_.-..Distance fsrom foy�datn--- , -----..Material-- t ¢ •-------------- No, of compartments_-- -.......--------Size�..�_rl'"�'>6 _Liquid depth.....41e--------------Capacity,/� .--. Disposal Field: Distance from nearest well__ ->�---"-_Distance from foundation�r _--..._.DAstance to nearest lot line--,, .-....` RK Number of lines. •_-- _ - --__ ength of each l tt�' =� t.VVid+h of french----- --_.__- ------•--------- Type of filter material.,/ epth of filter material._-,-------------Total length___�._-9- ........... -•--.. Seepag Pit: Distance to nearest well-"---./�,�_ --Distance fr fou dation__ _..__.Dis+an`e to nearest lot line--: Number of pits----_. -------Lining material_ Size: Diameter-- -.---.____Depth-- ..................... Cesspool: Distance from nearest well-----------------Distance from foundation-------------------.Lining material------------.------------___--_....._ ❑ Size: Diameter--------------------------------------Qepth-------------------------------------- "------------Liquid Capacity.------------_-------••-•-gals. Privy: Distance from nearest well-------------------------------------------------------------- -.....Distance from nearest building------------------------------------ ❑ Distance to nearest lot line.-----------••--------f- ----------------------- ----- Z_--------X- C-1.1----------------------------------------------- --- Distance and/or repairing (describe):-------- -.11-------------------1-1------------------- --------••--------------------------------- - -----------•-------- •-------------------------------•-------•-•---------------------------------••------------------------------ ------------------- ----------------------- -------------------------I--------------------- --------- --------- --- ----------------------------------•--•--------- •-------------- --------•------•-----------•---------------••-•---------------- -------------------------------••--•--------------•-------•------- 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 reg tions of the San Joaquin Local Health District. 6 - ---.-.(Owner endfvr�trector) (signed).. -•---------- i Itle.""_-- _-- By:----------------------------------------------------------- = --Fi ) -� ....-..-..-.-... (Plot plan, showing size of lot, location of system in relatio ells, buildings, etc., can be placed on reverse side). FOR DE ARTMENT USE ONLY APPLICATION ACCEPTED BY"-"-r2 _._ _ ---- "'�-`� "_ __ DATE------ r�� -�� REVIEWEDBY--- ----------------------------------------- --------------------------------- --------------------------------------------- DATE-------- ---•------•--------------------------------------- BUILDINGPERMIT ISSUED....---- ---•----------------, ------ -----------•------------------ DATE....--------------•--- •-----------,-r--------------------•----- f�e tG� za L , lC ,..-- , ',`�:,=�-_.------ �``"` �.. Alterations anal/or-41� _recommendations...-----. .�_.._s-=-'�.___.---"--- f�--�'-'�-•-----••-- -`7---� 7- �� 1 --------- --- .............................................................•--••----.... -------------------------------------- -----------------------------------------I"--------------------------------------------------------------------------------------------------------•------------••-- ------------------------------ --------------------- -------------- FINAL INSPECTION BY:.. ,-_... ._ -"--_-------- Date----- __� .�---------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South Amerlcan Street 300 Weil 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