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FOROFFIU dE^:{ /LT1( 7 ___....__.. .� --;_� _._.. APPLICATION FOR SANITATION PERMIT Permit No. APPLICATION -= �. _ � ---��`�� - (Complete in Duplicate) Z �� --- - ---- -- - ----------------- ----- ------------ This Permit Expires 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 0r di rete No. 549. aa JOB ADDRESS AND OCATION------- �7- �✓I" G' ------_------------------------------------••................... Owner's Name_> r �_.: ---._. Phone.................................... Address..._... IX21. - Contractor's .Name------ Phone Installation wills serve: Residence gpo'*Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ i Number of living units: __<____ Number of bedrooms J. Number of baths___ Lot size .1,9,FO<. --_-__-_-•------------------- Water Supply: Public system ❑ Community system [Private ❑ Depth To Water Table ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe &-Aardpan ❑ Previous Application Made: (If yes,date--------------------) No 9?' New Construction: Yes 9�No ❑ FHA/VA: Yes Z?-'No ❑ TYPE-OF INSTALLATION AND SPECIFICATIONS: (No septic lank or cesspool permitted if public sewer is available within 200 feet.) � BB QQ Septic Tank: Distance from nearest well___`r'_-_Distance�rom ndatMn---1Q___-__-Material__f1'_ [�' No. of compartments_,?_-----•____..___Sized _ '__ Liquid depth-------.....well--- ----- foundation---/ to nearest lot line__tr,e.... Number of lines------ ___ _ _ �/Length of each line__/s��_ Width of trench/...�g..r______ __________________ Type-of filter materia14� &--T,dDepth of filter material_._1 _____ Total length__/___s!_ ..•--------------------- Seepage Pit: Distance to nearest Yrell____�'______Distance fr m fo dation_., __._...D' r�ee to nearest lot liQe__.s........ pUp�)� Number of pits_____ _______________Lining material_,r ..Size: Diameter__ ____...___Depth__ .0 �______-_____..-. V' Cesspool: Distance from nearest well-------_---------Distance from foundation-------------------.Lining material__.___--___-_______-_-__________._._ ❑ Size: Diameter-------------------------------------Depth----------------------------------------------------Liquid Capacity---_------•---------------gals. Privy: Distance from nearest well-------------------------------------------------Distance from nearest building__________.__-_._._..--_______.._________- ❑ Distance to nearest lot line------------------------------------- ------- - -------•----..... -- ---------•------------------------------------------------------- �, Remodeling and/or repairing (describe):--------- fir- -- ----•--••---------------------------------•----•--------- � �y •-•--- •-••-------------------------• •----------•-----------------•---------•------•-•---•-----------•-------•------------- -----------------•------.------------•------------••---------------------------------------------------------------...------------------------------------------------------------------------------------ -- ------ 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, d rules and regulations of the San Joaquin Local Health District. (Signed) 7.---- - --------- for Contractor] By:........................................ ------ In --------------------------(Title)---- � -----------.....-- ------------- (Plot plan, showing size of lot, location of sys in relation to wells, buildings, etc., can be placed on reverse side). -�t ,FOR. DEPARTMENT USE ONLY APPLICATION ACCEPTED BY_ 1 DATE REVIEWEDBY---------------------•-------- --------------- ti;, -----....------. DATE----------------------------------- BUILDING PERMIT ISSUED------------------------------------ --------------------------.--------------- DATE------------------------------------------------------------- Alterations and/or recommendations:----------4`�-4r- -- --- ---- .aG ___._ — -t ___ _�- �� - --- ........ l r --------------- ff. -•---."`_.-- ----..------••------- -------- •--•-•------------------ -------------------------------- —. FINAL INSPECTION BY:�...._., --------------- ---------------- Date �--�--- --------- ------------ -------------------------------.- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 124 Sycamore Street 205 West 9th Strout Stockton,California Lodi,California Manteca,California Tracy,California ES 9 REVISED 8-59 2M 5-82 ATLAS - ,,, .