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FOROFFICE USE: ► - --------------------------------_---------------. APPLICATION FOR SANITATION PERMIT Permit No. .. ......_____ (Complete in Duplicate) Date Issued ///Z�_ I This Permit Expires 1 Year From Date Issued _ .7....... Application is hereby made to the Sen 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. S49. 4- JOB JOB ADDRESS AND LOC TION_, f_ /?r„ -• ��i� `- ', , C�I-too—lS Ownerst --- lf. uv------- ----••---------•-------•---------•--- Phone.................................... Address......................... 'l l __ /_-/---•-•----------------- ----_---------------------_---------_-•-----------..................... Contractor's Name....�:--_-------------------------•---------------------------------------------------------------------------------------- Phone................................... Installation will serve: Residence IN Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units-.-l-..... Number of bedrooms ..-S- Number of baths _ _ Lot size ...1.'.••tr! ---�4 > Water Supply: Public system [-] Community system ❑ Private ® Depth to Water Table -----_ ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel E] Sandy loam ® Clay Loam ❑ Clay ❑ 'Adobe❑ Hardpan C]Previous Application Made: (If yes,date-------_-----------1 . No N New Construction:�'Yes E�4 No ❑ FHA/VA: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPEIFICATIONS: / (No septic tank or cesspool permitted if public Isewer is available within 200 feet.) s Septic Tank: Distance from nearest well-----------------Distance from foundation-----------------Material ..---------...-._._----____._-...........--.___. ❑ No. of compartments Size --Liquid depth--------------------------Capacity....................... Disposal Field: Distance from nearest well_---------------Distance from foundation----____----____-__-Distance to nearest lot line_____-........... W ElNumber of lines--I-----------------------------t-Length of each line___-.---____r-------_-------_-Width of trench----- ----------------- �n "f Type of filter material-------------------------Depth of filter material-----------------------Total length___----_---_-_____-__---__-_____-_--_-__-- 'h Distance to nearest well----S�iP!------------Distance fro foundation-_yp� ---------Distance to nearest lot line- ..-_---__ �] Number of pits.._(I---------------Lining material,) -----------Size:-&�rf �-..�---.Depth----.6.-`.-•-------------------- Cesspool: Distance from nearest well_--__-.-------__Distance from foundation-------------_---.Lining material----------------......... -_____..-_- ❑ Size: Diameter-----i---------------------- --------De Depth -------•------------------------Liquid Capacity-------...----------....--•-gals, Privy: Distance from nearest - rest well-----------------L---_-__----_-_---------_ .-_-_Distance from nearest building t r r} 9 ---•-- ❑ Distance to nearest lot line =---------------------------------------------------------- -----------------------------------------------.. -------------------- Remodeling and/or repairing (clescrille):_- {--- -'Z.------ ' ---.-.-..---.I----..-.-- .._....... -------••------•----------- •----------------- k4 2....... .. .........-' ----•----- - ------•-•- --- --- A- _ -. 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 regulations of the San Joaquin Local Health District. (Signed) arl ...: A-s-,f ------•••-------------------•-------------------•-------_(Owner and/or Contractor] - -- -- _ _ _- - .�.�- By= - ---------------------------•-•--------------------------------- � [Ttle)`--------------------------------------- - ---------------- (Plot plan, showing size of lot, location of system in relation fo wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY - - -- - --------------------------------------------- DATE -'I�"6r-�------------------------------- REVIEWEDBY-----------------------------------------------------------------------------------------------•---------------------------. DATE-----'------- BUILDING PERMIT ISSUED----------------------------------------------------------------------.-. ------------------------- DATE. Alterations and/or recommendations:---------------------- ------------------- ••---- - -------------------------------------------------------------------------------------------- ---•--•-----•---------------•-----------••-- ----------••------------------------------------••----- •----------•----------------- ---------- ---- - •--------------------------------------•----------------------------------------•---------- ------------------------------ ---------------------------I— •--------••-----. ---•--- FINAL INSPECTION BY:-. _ _ --- >/ 1 -•---- Date-- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 Wist Oak Street g 124 Sycamore Street 205 Weil 9th Street Stockton,California Lodi,California Manteca,California TraWr California E8 9 REVISED 6.59 2M 3.61 ATLAS