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FOR OFFICE USE: i ------------- --------- ---------------------------- ------------------ -------- ----- -- / _.- APPLICATION FOR SANITATION PERMIT Permit No. --------------------------------------------------------- (Complete in Duplicate) --- - ------------------- --.--.- 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 OrdinanceN549. o. JOB ADDRESS AND LOCATION:__ .f ----A� -------xc�z --------------------------------Ir _------....•_....---•-•---......................... Owner's Name_/��_�.Y----A-Iy....e26t .�-_---- ' --•------- -----_-�.. Phone.-•-!-q----^-•D 72U Address ----------------------------- ------ 016;.11 .-------_-_-------- ----- - .. ................. Contractor's Name........ r. :.i /, / ... ---aQ1t.ZS---- 1�JC Phone..,1J7�` Installation will serve: Residence ❑ Apartment House ❑ Commercial ❑ Trailer Court 0 Motel ❑ Other Number of living units: -------- Number of bedrooms -------- Number of baths ... tot size ______________ _--_-_•- - Wafer Supply: Public system ❑ 'Community system [] Private &--Depth To Water Table . ft. Character of soil to a depth of 3 fee+: Sand [[Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe❑ Hardpan ❑ Previous Application Made: (If yes,date..................,_.) No New Construction: Yes .E3-"No ❑. FHA/VA: Yes ❑ No P" TYPE OF INSTALLATION AND SPECIFICATIONS: (No sepfic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tank: Distance from nearest well____ � Distance from foundation__._fp........Material_____C � ,---__----_. gf No. of compartments--------7�---------Size_3_.X__-.-,_x--- •---Liquid depth------- ----Capacity ._.. ' Disposal Field: Distance from nearest well----,` '._._Distance from foundation...__6d--------Distance to nearest lotline.___ �_.._.... Number of lines.............1_._-.-----______._Length of each line_____-_----7 -`_.___._.Width of trench._____. Type of filter material-_-�2_QC_je_..,Depth of filter material------/8_"_....Total length_________________ ----•------------ Seepage Pit: Distance to nearest well----------------------Distance from foundation....................Distance to nearest lot line---------I....... r ❑ Number of pits----------------------Lining material-----------------------Size: Diameter------- •------------- Depth---------------- Cesspool: Distance from nearest well_________________Distance from foundation-------------------.Lining material__.____-_._..___ :_:_ El -------gals Size: Diameter------- •---------------- q P---------•-DePth----•------------- ---------- --------- -----------.Li Liquid Capacity---.-- ------------------ . -Privy: `'Distance from nearest well-______.__.-- "=-__- - -----~"--'Distance from 'nearest building_____________ ' --•--••-- ❑ Distance to nearest lot line........ ..--•--------•------- Remodeling and/or repairing (describe):_____ !;2a .--- �cry--- ---------------------------------------------••-- •-------------------------------------••------------------------------------------------------------------------------ •----•---•.----- •------------------------ 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 Disfrie. (Signed)---------------- ' f '' -- ._ - ----�---------------- - - ----- _-- ----------,-_-(Ow,,n� and/or Contractor) By:............... ------ -----• �. �_. ------ (Title) - - _ (Plot plan, showing size of lot, location of system to relation to wells, buildings, etc., can be placed on reverse side). t FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY--------------------L------------" - --- -- - -- -- DATE__ --------------- --- REVIEWED BY = '----------------------------- -- DATE f`i.' ' ------ - ----------------•---- ------------- U1 DING PERMIT ISSUED ------------- DATE. ---- ... --------• ` � •------------------- Alterations and/or recommend'afions:.________"__________ _________._ ..................j- -------------------------------------- - - ------------------------- ---------- - --- ----- -------------------- --------------- --•-----•-- . FINAL INSPECTION BY:---- :-4 -,If—e �ate ---------------- SANSAN - JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,Californla Lodi,California Mantua,California Tracy,California ES 9 REVISED 8-59 2M 5-52 ATLAS " "�- ,1 F