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FOR OFFICE USE: £b� I G�afv °z-� q2, --------------------------------------------------------- APPLICATION FOR SANITATION PERMIT Permit No. .1Z --------------------------------------------------------- (Complete in Duplicate) Date Issued ---------------------------------------------------------- This Permit Expires 1 Year From 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 County Ordinance No. 549. JOB ADDRESS AND, LOCA ION---T• _ .............SJ J .--1 �.. -. ........... Owner's Name.... 6 ----------------- --- --------- -- Phone - Address_.�s___.�� I �z� Contractor's Name------------------------t--------------------------------------------------------------------- ........................................... Phone................................... Installation will serve: Residence M Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of livingunits: _ GD �___. Number of bedrooms ___1___ Number of baths ___�.._ Lot size ____ _ X �� Water Supply: Public system ❑ Community system ;I 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 0 New Construction: Yes j&,No ❑ 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_. 0#'Dista�nf a from foundation....,�0_........M tprial.. _ ........... ( ..._r___Liquid de th._. _. ru.--_ Capacity... ,l-O© No. of compartments.._'Z" Size.Tl _ x.__.___. q R ^ ' Disposal Field: Distance from nearest well.�'04'F'_Dis rete f tion_._./r ..._ Distance to nearest lot line....... �i Number of lines '� j_ _______ ______ _ Leg o e c Ine.__._..________ Y� Width of trench-__i�__<'�................_..... rr 0 Type of filter material�T _.Depth of filter material________________Total length_.___ �." ...................... Seepage Pit: Distance to nearest well--------------.-------Distance from foundation....................Distance to nearest lot line................. 0 ❑ 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 cerfWf_that:, ve prepared this application and that the work will be done in accordance with San Joaquin County (�'} ordinances,,SWe laws, aft'`ru d regulations of the San Joaquin Local Health District. SI ------ -------- -----'- -- ---------------------------------------------=----------------------------------------(Owner and/or Contractor)�1 , By:--------------------------------------------------------- -------------------------------------------------------------------------(Title)------------------------------------------------ --- --------- (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 APPLICATIONACCEPTED BY...------------------------------------------------------ --------•------------------------------- DATE............................................................ REVIEWEDBY--------------------------------------------- -------------- -- -- -----------------------------------••-• DATE...... BUILDING PERMIT ISSUED - ---- -- -------- DATE - - Alterations and/or recommendations-------------------------------------------------------------------------------•----------------------•----------------•-------•-----------•------------------- •----••••---•--•---•---•---•---------------------••--•. ......................------------------------------ •-----•-------------------------•---•----••-••-----••----------------••-----•--•-••-----••••-•-•---•••------. -------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- -------------------•--------------------------------.....------------------------------------------------------------------------------------------------------------------------------------------------------------------ ------------------------------------------ ------------------------------ ------------------- ----------------------------------------------------------------------------------------------------------------------- FINALINSPECTION 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 ..�