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FOR OFFICE USE; ------------------------ ------------------ ------------- , ------------------ -------------------------------------- APPLICATION FOR SANITATION POMIT Permit No. ... s_.. / --- ----------•------------------------------------------ (Complete in Duplicate) -------------------------------------------- This Permit Expires 1 Year From Date Issued Date Issued .__�� y 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 LOCATION------•-----------------_-- �- --- �/ 4 } Owner's Name...... ------ r C'e ------ -- Phone-------••--------Q----.-.•.•- �.�--`---.C-f-f-�- -0- - Address-•----.........25Pm- Contractor's Name------------------- _ .. .-.._ Phone----.....---....................... -. Installation will serve: Residence Q�'_Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ i Number of living units: __l-_.- Number of bedrooms . Number of baths ---_.___ Lot size ___. '7_� -- ..)C.. .��" _...___._._ Water Supply: Public system ❑ Community system ❑ Private 5?,-Depth To Water Table s..-. ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam Q"'Clay Loam ❑ Clay ❑ Adobe❑ Hardpan ❑ Previous Application Made: (If yes,date-------------- No ❑ New Construction: Yes []/No ❑ FHA/VA: Yes ❑ No fi TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted'if public;ewer is available within 200 feet.) Septic Tank: Distance from nearest we1l_50t!! ,,DistaPce i � fromr-+--oundation_IQ_Al_R_r.MaterialT _ COapact(y.-... ` +___ i)4, No. of compartments_-__-_..._ ___Liquid depth--------- C _ - Disposal Field: Distance from nearest eli_ -AfILs_Distance from foundation.1.4.6!111_--_-Distance to nearest I t KA Number of lines-. Length--------- Len th of each line------- _ �.......-_---- g �?_..�..._.._-Width of trench_____ ________ Type of filter materialrjG' ,_�` ----Depth of filter material------- r-_________-_Total length______- _ __ ._.- 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------------------------------------- r_1 Size: Diameter--------------------------------------Depth----•----------- -----------------------------.-----Liquid Capacity----------------------------gals, Privy: Distance from nearest well_________________ ___________•_________-_-___-_Distance from nearest building__--.____-_________-...._.______--____-_. ❑ Distance to nearest lot line -._.._ r F Er� Remodel in and/or repair' g (de ribe),___ , . � - r ---•--•--- ..._ y- ...._. { - hereby certify that I ave prepared +his application and that + w will be2��ce with San Joaquin County ordinances, State laws, and rules end regulations of the San Joaqui Local Heal+h District. /a (Signed)- -- '.1 '-5: �% ?_ w ,� ----------- ------------------ - --- --•- •----------------------------{Qrrner and/or Contractor) - - - 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 APPLICATION ACCEPTED BY ------------------•------ f .._ DATE -------- REVIEWEDBY-------------------------------------------------------------------------- ---------------------- -------------------•---•--. DATE-----------------------• BUILDING PERMIT ISSUED------ ------------------------------------------- •-••---•--- DATE-------------------------------------------------- Alterations and/or recommendations:-------------- -----------------------------------------------------------------.---•------------ --•-•-•----------.-----•--------------------------------------------•- ----------------------------------- ----------------------------------------------- ..........-----.--•--•------•------....--------------. ---------- ------------------------••--•--•----------------•----------- ,ole I FINAL INSPECTION BY:.- S"6 - - - - - - �v�f.��.---------------------- Date--------- ----k�,�. -.._._..-----------------------------------------•---• SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 Wert Oak Srreet 124 Sycamore Street 205 Wert 9th Street Stockton,California Locil,California Manteca,California Tracy,California E5 9 REVISED 8-59 2M 5-62 ATLAS