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FOR OFFICE US - - --------- ----- - -------✓-------------»'//5`----------!/..___. 9 APPLICATION FOR SANITATION PERMIT Permit No. ---------------- --------------------------------------- (Complete in Duplicate) / ------- I 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 Ordi nce No. 549. JOB ADDRESS AN LO ATION__ Owner's Nam - - --- Address hon Address-----------------•------ • ----- -- -- Contractor's Name---------------- �r � � Phone;?bA/9._-.?4o! Installation will serve: Residence ❑ Apartment House ❑ Commercial ❑ Trailerr, QV ❑ Motel ❑ Other [� Number of living units: ........ Number of bedrooms -------- Number of baths _- o size ------- Water Supply: Public system ❑ Community system ❑ Private �pth TOWater Table,,5o_ ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ . Adobe iardpan E]Previous Application Made: (If yes,date____________________) No ❑ New Construction: Yes Jo ❑ FHA/VA: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) I !� Septic : Distance from nearest weli_.v�_..._...Distance from fou ation.__�2---_ Ma eyial__ 2 ..________ _. ._ No. of comportments.-_._ ..____.._�.-Size _ Liquid depth___ ----------------Capacity.. 0 __ _ Disposal Distance from nearest well--- --_Distance from foundation--/AD _ _._.._._.D�stance to nearest lot Ione—_01__._.... Number of lines__...__.__ _____ Length of each line__0RS.___________- ._-Width of-trench.-____a7 fit___________ __•. _ Type of filter materia • YP �i-- - --- f ---Depth of filter material--��-----_---Total length-------------------------2_,�!_.. 5eepag i : Distance to nearest well. �a_--___Distan e m f undation_ ___R__ ista��P to nearest lot line------ --------- 4f Number of flits------- -------------Lining materia.C-711 Size: Diameter- ,� De th__ r I -------- p ��' 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------------------------------------- --•----------------------------------•-- .. --_._.Vk-6{- C,2-L-- '" 'kQU,GL 4��-..�F -Getlf- 1. Remodeling and/or repairing (describe): ------ --- � � - - ------- --- - =--� - ------- --- _-..... t -----------------------------------------------------------------------------------.--------------------------------------------------------------------------------------------------------------------------- ---- I hereby certify that I have prepared this applic tion and that the work will be done in accordance with San Joaquin County ordinances, State laws, and rulen regulation of + e San Jo u' Local Health District. w o (Signed)-------- •-• ---- ------ --- ------ ----- ----- - (Owner and/or Contractor) sr• --- -----,- -- ----V--- --------------------------------------- (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY--------- DATE_... // -- ------------------------ -------------- REVIEWEDBY --------- ---------I--------------------------------------•-,---------------------------------•---• DATE- BUILDING PERMIT ISSUED - '---------------------- � DATE �_. ------------ Alterations and/or recommendations:--------------------------------------- ---------••---•-•- a ... --- - - ---- - �- ---- - -----...l----------- FINALINSPECTION BY:---------------------------- ---------•- ---------------•- Date-----------•--------------------•-------------- ---- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Srreel 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,California G Manteca,California Tracy,California F:5 9 REVISED $-59 EM 5-62 ATLAS n