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OFF ICSE'� - �,e- -------------------- ----- _ "—"_ APrLiCAT.ION FOR-' SANITATION PERMIT Permit No. ...1.��.�'-.. -------------- ------ (Comphvte in Duplicate) - Date Issued ----------------_-- ------------------ ------------------------------- -••--=-----••------________ - ---------------------------------- this Permit Expires l Year From 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 Ordinance No. 549. JOB ADDRESS AND LOC TION/...' -- r -Al' --------------------------------------------...........--•--------.._...------•------------ Owner's Name --------------------------------------------------------------------------_-----------. Phone------------------------------------ ------------------------ ------------------------------...-----------=-------------••-- ................................... Contractor's Name---- r >� ---•--------•-•-----•--••.............:........ Phone............................------- Installation will serve: Residence ❑ Apartment House ❑ Commer I� Trailer Court ❑ Motel ❑ Other ❑ I Number of living units: _.:_.__. Number of bedrooms Number of baths _/-- Lot size --------------•••---••------- r lr Water Supply: Public system ❑ Community system ❑ Private �epth To Water Table ' 'Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe 0 Hardpan ❑ Previous Application Made: (If yes,date--------------------) No P'O"New Construction: Yes ❑ No (7ge-`FHA/VA: Yes ❑ No 9. TYPE OF INSTALLATION AND SPECIFICATIONS: :. (No septic tank or cesspool permitFed if public sewer is available within 200 feet.) i J 1 ✓ Se is Tank: Distance from nearest well-----------------Distance from foundation.-.------- --.:-.Material----_--------.----.----..-..-...__.---._--_---- No. of compartments-------------------------Size---------------` •------.Liquid depth-_----------------------Capacity------------------_-- Dis osaf-Field° Distance from nearest well--- ----------Distance from fRundation....................Distance to nearest lot line----............. i A0144y Number of lines---------- --•---Length of each`line--------------------_------Width of french.--------•------------------------- .� Type of filter material-------------------------Depth of filters material..---------------------Total length------------------------------------------ —J Seepage P Distance to nearest well.--1A0_ --Distance fr m f ndation../4�_._..._..Dist nce to nearest lot king �! {n Number of pits...... material--/ Diameter _..___._,De Depth I Lining material ...-.._ P r--------------- .-r Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material--...__-_.._.-------------__,... Size: Diameter--------------------------------------.: Depth ------- ----------------------------Liquid Capacity.. ---------••---------...gals. I _. Privy: Distance from nearest well---------1_1�------------------------------------Distance from nearest building---------------•----------•--------------- ❑ Distance to nearest lot-------------------------- line--------------------------- ------------------------ •----------------�• --------------------------------------- r 1 j . F Remodel'ng d/or repairing (descri ) �" { �-!�`- •�T--------------- �qq -- ---------------------------------------•-------------=--------------------- hereby certify that I have prepared Ais application and that the work will be done in accordance with San Joaquin County ordinances, State laws, nd rules and la+ions of the San Joaquin Local Health District. [Signed} Contractor) r - sr• By:--•--s�i ! --=------ -------------------------------------------- m ----=-" `=--- -- -------- a Title]- l' (Plot plan, showing size of lot oca+ion of.sys+em in aft to walls, buildings, eta., can be placed on reverse side). *` F1611 DEPARTMENT USE ONLY APPLICATION ACCEPTED BY------�ak-_z�-------- ---------------------------------------------------- DATE---- - -------------------------- + - REVIEWED BY-------------------------- •"` - = _:-:----------------------- DATE---- ...--•-------•------ BUILDINGPERMIT ISSUED----------------------------------------------------------------_ _ ------------- DATE------------------------ Alterationsand/or recommendations:------- ---------- - ------------------------------------------•-•-----------.---------•-•------------------------------------------------------------ i ------------------ ----------•-------------------•--------•--------- ---------------- -----------------------•------------------------- ----------------------------- -- k `•• ----------i- ------------------- - -------------------------- ---------------------------------------------------------------------------------- -------------------------- - - - -- ------------------------------- , -----------------• Date----.�L..�.f. j.-r.F? -'_... ----------------- FINAL INSPECTION BY:..--C............ --------- ---------------- SAN JOAQUIN LOCAL _HEALTH DISTRICT a ' �'4' 4y " A t 1 205 Weil 9th Street 130 South American Street 300 West Oak Srreet � � 134•Sycamore S�net� � � . Stockton,California Lodl,California Manteca,California Tracy,California ES 9 REVISED 8.59 2M 5-62 ATLAS