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O OFFI-� � { Permit No. ; ........ APPLICATION FOR SANITATION PERMIT ��j�� ----------------------------- (Complete in Duplicate) Date issued ..-- -.-•--••--- - ------------____-----_.--- This Permit Expires 1 Year From Date Issue Application is hereby made to the San Uoaquin 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. �_ s" �1---- & .--- ----------------------------------------------- JOS ADDRESS AND LOCATION-------------"---------• ----------- -- -- .._ -------------------------- Phone.........-----_-------•-..-..-----. Owner's Name--------!0%--------------•_ ---••-------------•---------------------------- ------ ------- --------•-------- Address-_._ `�3 .__.-w--- --------------- --------------------------------------------- Phone----------------------------------- Contractor's Name------- ---------------- --- ------•----------------------------•-- Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ --- Number of baths -.`�:-- Lot size .•---7�'-x-�a�-------------------------------- Number ---•--------•-------• - --- Number of living units: ---2—Number of bedrooms _ , Water Supply: ,Public system �ommunity system ❑ Private ❑ 'Depth To Water Table -4-P ft. ClLoam [I Clay ❑ Adobe[Hardpan C] of soil to a depth of 3 feet: Sand ❑ Gravel E] Sandy Loam ❑ y No, FNA/VA: Yes ❑ No Previous Application Made: (if yes,date-------------- --- ) "No New Construction: Yes ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tank: Distance from nearest welt-----------------Distance from foundati�ln Liquid depth_Material------------------------------------_ acity------- 0 .__..--..---.----•- No. of compartments---------•----------------Size--.------------ q ❑ r Disposal Field: Distance from nearest well-------- -------DLength of istance from each line anon--- ----_-.Width ofttrench----------------------------------- 0 st lot ine=_.-------- ---- E ❑ Number of lines----------.- Type of filter material-------------------------Depth of filter material. length-_--.------------- -••- - �-------•-----• Seepage Pit: Distance to nearest well_' ---- Distance rom oundation_ ------.��---Distafce to nearest lot Gn -� _----._--.. Linin material.. --------Size: Diameter-.�1..--Depth...... �- -------- Number of pits.I l-- ---------- - g ing Cesspool: Distance from nearest well-----------------Distance from foundation-_ -----=-_--__-_Linuid Capacity gals. ' Size: Diameter__;�- ----------Depth----------------------- 9 p ty Distance from nearest building l Privy: Distance from nearest well------------------------ ___----.--.- ❑ Distance to nearest lot line--------------------"------- ------------------------- I -- 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 and regulati ns of he San Joaquin"Local Health District. - --_-..---(Owner and/or Contractor] i (Signed) - -------- --------------•--------•---------------•----------------- - a --- - ( g ---------------------------------------•------------ l ---------•---------------------------------- BY: = - --------- ----- -------------------- (rt Is) (Plot plan, showing size of lot, Iota on of stem in relat' n to wells, buildings, etc., can be placed on reverse side]. �. FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY---- __ --t DATE-------=r�/�� .� �-------- l DA --------•---------•-- REVIEWEDBY ----------------------- DATE------------------------------------•------------------ BUILDING PERMIT ISSUED-------------------- -----------------------------------------•------------- ------- Alterations and/or recommendations:. x ----------- ------------r--,---•-- Y /- --••------------- _ 2 ----------- --------- n 42�- ------------= — --- --• _v,�� ,{r 631�e o --------------------------------- Date--. - FINAL INSPECTION BY:.---- ---"--- ----- � 4l SAN JOAQUIN LOCAL HEALTH DISTRICT —±+ 124 Sycamore Street 205 West 9th Street 130 South American Street 300 West Oak Street Manteea,California Tracy,California Stockton,California Lodi,California - e E5 9 REVISED a-59 2M 5-62 ATLAS