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FOR OFFICE USE: ......................................................... APPLICATION FOR SANITATION PERMIT Permit No. .., -5.. .... --------- ------ -- ---------- (Complete in Duplicate) Date Issued ... - ---------------------------------- --------------------- This Permit Expires 1 Year From Date Issued .1-1_.. ....__. 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 LOCARION__.�.._ /,,� c ..............................................�j Owner's Name 10 5 .. hone......................... Address........... ..0..... R." --------------------------------------------------••---•------•----•-••-------•- Contractor's Name.................. ... .....................---------------------------------------- -........................................... Phone.._.......... ............ Installation will serve: Residence'] Apartment House ❑yC'ommercial ❑ Trailer Court ❑` Motel ❑ Other Number of living units: ..___ Number of bedrooms .-_!__ Number of baths .:t__- Lot size ... -------------------------- moo Water Supply: Public system ❑ Community system 15f.,private ❑ Depth To Water Table ,� • ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay�Adobe❑ Hardpan ❑ Previous Application Made: (If yes,date--------------------) No A New Construction: Yey.)RtNo ❑ 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___ _Ap-__Distanc om uJn�dat�io ____. Q...__.Maatt r:lpl. ............... ....... ...... `�' - L- No. of compartments._ Size___ __._ Liquid depth_________ , _Capacity__/_.?��. _.. Disposal Field: Distance from nearest well 5"......Distance from foundation..114.........Distance to nearest lot line.�.. Number of lines- -4, -----`---------�ength of each line_2. " ' ii�f trench......�.�7l '__............... Type of filter material. th of filter material ,l_.�.'1!Total length........440.,o................. Seepage Pit: Distance to nearest well-------------------•-_Distance from foundation....................Distance to nearest lot line................. ❑ 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.......................................... ❑ Distance to nearest lot line------ ------------------------------------------------•---------•--•------------•------------•-•------------•----------•--------------------- Remodeling and/or repairing (describe):---------------------------------------------------------------------------------------------------------------•--------------------•••-----•----------- --•---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------•---------------------------------- ------------------------------------------------------------------------.....................................................--------------------------------------------------------------------------------------- ------ ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ 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 a d regulations of the San Joaquin Local Health District. 1A (Signed).......... ..-- ... ------------------------- ------------------ -- (Owner end/or Contractor) By:-------------------•--•------------------------------------------------------------------------------------------------------------(Title)---------- ------------------------------- -------------------- (Plot ---------- --------(Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY-------------------------------------------- ---------------------------------------------------- DATE................ REVIEWEDBY. --------------------------------------------- --------------------------------------_.. DATE------b -,'-ri.••„'r BUILDING PERMIT ISSUED---------------------------------- ---------- Alterations and/or recommendations:-------------- ------- -- -----` --------.------------------------------------------------•-------------- FINAL INSPECTION BY:. --- - -- �.. Date------- ._ . SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West 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