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FOR OFFICE USE: I - --------------------------- --- Permit No. ---- ------------ ------ -------------- APPLICATION FOR SANITATION PERMIT �•---••-j-�•-• ----------- qq/ --- -------------------------- (Complete in Duplicate) Date Issued F This Permit Expires 1 Year From Date Issued Application is hereby made to the Sa Joaquin Local Health District for a per •t to constr ct and.install the work herein described.This application is; ad in com lin with Co.nty'Ordinancej o. 5 �- ��""`� 3 � JOB ADDRESS AN CATION...£ - `--d- -- F Owner's Name.----- -....... ' -----------•------------------------- -------- -----------•-------�---------- ------- Phone---------•--------_------•------- p ----------------- Phone-------------------------- Contractor's Name- ...._ Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ I Number of living units: __.�.___ Number of bedrooms _�___ Number of baths /2-- Lot size __ 7----------�-' -- ---••-•.......... 1 Water Supply: Public system ❑ Community system ❑ Private eDepth To Water Table -------- ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ElSandy Loam ZClay Loam El Clay [j Adobe❑ Hardpan ❑ i Previous Application Made: (If yes date____________________7 No ❑ New Construction: Yes V31/No ❑ FHA/VA: Yes ❑ No El L TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Sep2, lank: Distance from nearest well---_ v- -Distance from foundation.----1.B-.----__.Material----��--:�s-f'�1!' dx.�..-----••,--•• Size_,f .� _ O-X- .Liquid depth - .°-----Capacity---1- No. of compartments_---_. c lr Dispo Field: Distance from nearest well.-�D__f--Distance from foundation._...I-f�_---- Distance to nearest lo`line____LS..__..___. e Number of lines_ ----• --- -- Length of each line----.---- f�.............. of trench._--. -___--7 Type of filter material.-----j1- v,___Depth of filter material-------f"1--'..----Total length-------- =-a--__._...---•--------•- s UA ,f. A ' undation----1_ ----------Distance to nearest lot line----- g -----Depth-----�` -----• Seeps a Pit: Niutmberr of pits ance to rest-well--------LP m----mat Distance f- -" --Size: Diameter-----_r��a § Cesspool: Distance from nearest well_________________Distance from found ation--------------------Lining material------------------------- -- els. 11 ElSize: Diameter- -------------------------------- Depth.---------------------------------------------- Liquid Capacity--------------- -• 9 yPrivy: Distance from nearest well--------------------------------------------`.'Distance from nearest building--------------------------------•-----•--- Qistance 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 I , and rules and regulations of to San Joaquin Local Health District rD : kacrP��J+d ----------------------- (Si a ` r ..........(Owner_and/or—Contractor) ,. . (Signed}_. T _ _ �� [ ' By: - (T'itle} (Plot plan, showing size of lot, location of system in relation to wells, bail ings, etc.,'can be placed on reverse side), A FOR DEPARTMENT USE ONLY APPLICATIONACCEPTED BY- ------------- --- --- - - ---- ----------------------------------------------------------- DATE-- =l 3__`---- Z-------•-------------- ... REVIEWED BY-------------------------------------------------------------= ----------- ---------••------------ -•------------------------ DATE---------------------------------------------------------- BUILDING PERMIT ISSUED-----------'--------------•--------------------------------------------- ------ -------------------- DATE------------------------------------------------------------ ----------------------------------------------------------------------------- Alterations and/or'recommendaticns----------------------- ---------- ----------------••-----• �-...._ _ ---••-------_.. ----------• --------------- ----• -, G 1 FINAL INSPECTION BY --__._._ Date__.. .:`- --- -. -- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 124 SycamoTt Street 205 West 91h Street Stockton,confornia ! Lodi,California Manteca,California Tracy,California ES 9 REVISED 8-59 2M 5-62 ATLAS