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FOR OFFICE PSI/ ----------- ------- -- ------------------------------- APPLICATION FOR SANITATION PERMIT Permit No.1.�:._�i�`�-•, ----------- -1------------------------------------------ (Complete in Duplicate) c --------- --- This Permit Ex ires 1 Year From Date Issued 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. I JOB ADDRESS AND LOCATION'_5054--Kings_16y- Rc�_ .• .t.ackri Owner's Name.. R CZ3 _1 . _pe `------------------------ •- Phone.HO 5997 59978 Address---•----•-•-•-----------------------•-'5--��-------------- ----------- Contractor's Name`1'he gx &._. Axl ...Sep ic_..Tap.k---S_eL -----------•----•.............I........_ Phone.P9...�33L ._....._ Installation will serve: Residence$$ Apartment House ❑ Commercial [] Trailer Court ❑ Motel ❑ Other ❑ Number of living units: _1--__ Number of bedrooms ____g?Aumber of baths*--3 Lot size .........- __A Water Supply: Public system ❑ Community system ❑ Private (=Depth To Water Table5Q..-- ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe4 Hardpan ❑ Previous Application Made: lIf yes,date--------_-----------l No ❑ New Construction: Yes ❑ No4 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.___-_.____-_____._.___..____....____..___._.___. fisting No. of compartments------ ----------------_-Size--------------------------------Liquid depth---------------- ------Capacity I EDisposal Field: Distanc ._e from nearest well_.5()t------- Distance from foundation___111-------.Distance to nearest lot line----- �• �stjng & ber of lines.... •______•------ -------------Length of each line--------5Qt--------------Width of french 4 _•-------- (, Type of filter moferial_4p_' LC---Rkepfh of filter material----.-----19!! _.-Tota! length--------------------•--- --..------- V1 Seepage Pit: Distance to nearest well----1001----_Distance from foundation__.... _ xxu ], �.�t...__.Distance to nearest lot fine_..__�'�_.. Number of Pits__-___. -- ____.Lining material-,----materlalRal'k-.__.SDiameter 1 Size: er____.___ ame ------Depth------2-3r-t---------••------- Cesspool: Distance from nearest well______I_____._._Distance from foundation-----_-------------.Lining material__.- El -----------------•-------•----DepthLiquid Capacity -----------------------•--------------------------._Li Size: Diamefer__II--= 9 --------...-•--•-----.._..--gals. ' Privy: Distance from nearest well______ Distance to neares' _________________ t lot Disfance from nearest building -----•--------. ❑ line __ Remodeling and/or repairing (describe):__________________ __ _ 1 -.--••-------------••---...-----------•--••--•..--- ---------•------------------------------------------ •------- -------is-Upple-men ary----DrE Ma-9.0------------•----------------- ------------_---------_------------------------------------ i I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin Court ordinances, State laws, and rules and regulations of the San Joaquin Local Health District. ty 1•I (Signed)The---DAT--- ---N2GHT_._$*Ptic---T-ank-_Service---------------------- -------------- --------------(0t Contractor) By:------------•---------•----------------------------- (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----_QJ-__&1nAx5;_ --------•---------------- ----------------------- ------------ DATE----- �--`--�---- - ------ -- �- REVIEWED BY----------------- -------- ----•---------- ---•------------•-------------- --------- DATE------------- -•--..._. BUILDING PERMIT ISSUED------------- ------•--------- - --------------•------- ------------------------------•------------•-- DATE................ - Alterations and/or recommendations - ------ ------ ------•------ ---------•-------•-- -------•--------•----------•----•----- -------------------- FINAL ANSPECTION BY:. ....Q._ ------------------------------ Date..... la 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 �- Bracy,California ES 9 REVISED 5-59 ZM 5-62 ATLAS I