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FOR OFFI��SE _______________ __._____..____._..__._------------- APPLICATION FOR SANITATION PERMIT Permit No. .. ------------------------------------------------------- (Complete in Duplicate) / ----------- This permit Ex ires 1 Year From Date Issued Date Issued __.41k_-_. � Application is hereby made to the San Joaquin Local Health District for a permit to construct and iinstall-the wor herein described. This application is made in compliance with County Ordinance o. 549. el`72 0&„2 j JOB ADDRESS AN OCA N----- / ..._-..... .......... Owner's Name_ I � _C .� � -----•---•--------- --------------------------------------- Phone.............................•• Address------------------------ ----------------------------....__.....----------------------------•--- Contractor's Name........ ------------------------------------------------------- Phone................................... Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: j-__- Number of bedrooms ?--. Number of baths __J____ Lot size ............................................................ Water Supply: Public system ❑ Community system ❑ Private ®depth To Water Tabla3.1.. ft. Character of soil to a depth of 3 feet: Sand-0- Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe[g-'<ardpan ❑ Previous Application Made: (If yes,date--------------------I Noi3,Clew Construction: Yes ❑ Na FHA/VA: Yes ❑ No4�_;� TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) 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.__.......... ❑ Number of lines--------------------- ------Length of each line----------------.-------------Width of trench----------------------------------- Type of filter material_________________________Depth of filter material-----------------------Total length------------------------------------------ See I : Distance to nearest well Distance from foundation_/4.............Distance to nearest lot line_..._.__... [ Number of pits--------I--------------Lining material--.'k-QGr-__.._Size: Diameter--e.3_V__f7___,Depth_j5P�5_j------------------ 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_____________________________________ __ a ( esribeJ= � ------ - - - -Remodel and/o �re .......... �- = •-- ---------------------------------------------------------------------------------------------...-•------------------------------- ------------------------ ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, a ws, an and regulations of the San Joaquin Local Health District. (Signed) :.... -- - --•--------• --------- -- -------------------------------------------------- (Owner and/or Contractarl By----------------------- .... . ---------------------------------------(Title)---- - - -- .- ---------- --- ---------- a [Plot plan, showing size of I t, to ion of system in relation o wells, buildings, etc., can be placed on reverse side]. OR DE ARTMENT USE ONLY APPLICATION ACCEPTS --- ---------------------------------------- DATE .. .�� .... REVIEWEDBY------------------------------------------------ ---------- -----•----------- --------------------•---•------------•-•- DATE---- ---•------------------------------------------------ BUILDING PERMIT ISSUED---------------•------- �J------- - -------------•------- -- -• --- DATE--------•---_----------------- ------ Alterations enc!/or recommendations:.. 1 41----- � = 3 --C- ----==•--------------•---•---------------••-•----••-------------- -------•--------------- ------ ------------------------------------------------------------------- -------------•--•-------•-----•----.-.-----•---------.._---.-----•--•-••----•---•-----------------........-.---- -----•---••-------•--•-•---•-- ----- FINAL INSPECTION Y:--- ------- VINLO�C Date------ --------•-•------------ SAN JOHEALTH DISTRICT 130 South American Street 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,California Manteca,California Tracy,California E5 9 REVISED 8.59 2M 5-62 ATLAS