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FOR�OFFI E Lam, ---- --- --- ---IM...-___-___-_-.---------._...._.-- APPLICATION FOR SANITATION PERMIT Permit No. ...L. ......" -------------------------------------------------------- (Complete in Duplicate) 7 -h This Permit Expire; 1 Year From Date Issued Date Issued ._.11f 2� 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. 544. JOB ADDRESS AND LOCATION---• ----- --- --- ------ - --- - _3 - .......•- - :•- ........................... Owner's!Name... __.. ... .------••--•-••--•,-•--....... ------. - --------------•--------------------- Address ,iM -- -------------------......................................... Contractor's ------.- - —----------------------------------------------------------------------------------- Phone........................... Installation will serve: Residence E] ApartmenIt House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other Number of of living units: umber of bedrooms -------- Number of baths -------- Lot size ....................••_.---_•---------_.__._.--------------- I �h Water Supply: Public system ❑ Community system ❑ Private Depth to Water Table 4..k�ft. r Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe[3-14ardpan ❑ Previousl�Application Made: (If yes date......- -----------) No ❑ New Construction: Yes No ❑ FHA/VA: Yes ❑ No ©� TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) III SepticT,h nk� , Distance from nearest well.................Distance from foundation-------------------Material---------------------------------------------- ❑ o. of compartments-----------------------`-Size-------------------------------Liquid depth----------- ...... 71' Capacity Number of lines..... ....... ..._--_.---__-.-._ ' n t ,-,oundation__��`...._....Distance to nearest lot li�e.��,�:!•%� Disposal Field:. Distance from nearest well----( ..0..-..Distance from f �� Le g h of each line--- .........Width of trench.....�---�---------------------- Type of filter material._ _- __Depth of filter•ma#anal_._--.1-�j ------------------ ---------Total length.....,�' .......................... nn,^� jSeepagel Pit: Distance to nearest well .__..._..__..Distance from foundation--------------------Distance to nearest lot line•_......_.__...-- ^' ❑ Number of pits f--------------------Lining material-----------------------Size: Diameter----------------------.Depth--------------------------------- Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material._-......_.._...--------------------- jL/l ❑ Size: Diame#er.--?•---------------------------------Depth----------------------------------------------------Liquid Capacity-------------.--------------gals. Privy: Distance from nearest well-----------------------------•------•------------Distance from nearest building.......----------------••----------__---- ❑ Distance to nearest lot line Remodelling and/or repairing (desclibe):--------- ------------------------- ---------------------- --• - --••---------•---------------....----••---------------------------•---••---------•----...- --------- - -----------------•--•-------------•--------------------------------------------------•-------------------------------•-•------------------•------•----...--•---------------------•-------- ---------- ---------------------------•--------------------------------- "-----•----------------------------------------------- ...........................--------------------------------- i---------------------- -...-....---------------------------------•-•---------•------------ ----------------••----- -----...------------------------------------------------------------------------------------- I ht3eby 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 District. ff �f (Signed).q�_.__.... ------------ --------------(Owner and/or Contractor) $y--------------------------------------------------=----------------------------------...-------------------------------------.--_...(Title)------------------•------------------------- - - ------------- (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). F ! FOR DEPARTMENT USE ONLY APP6'1CATi6N ACCEPTED BY_.. ------------------------------ DATE----7_ /_�--- --- - REVIEWED BY -•------- DATE BUILDING PERMIT ISSUED---------------------------------------------- --------•--------------------------•-•--•---------- DATE-------•----------------------------... Alterations and/or recommendations:.-.--- --------------------------------------------.........•-------------------------------------- --------------- ... ' M I I II, -----------------11 ----•..................................I----------------.....-------------- 11 ...........................•-----........... = ------------------- -------- 3 FINAL' INSPECTION BY:... w� Date.......7--.......27—:77-'....6- 2----- ------------ SAN JOAQUIN LOCAL HEALTH DISTRICT t x T 130 South American Street 300 West Oak STreet 124 Sycamore Street ; y 205 West 9th Street Stockton,California Lodi,California 6 Manteca,California Tracy,California ES 9 REVISI{ED B-59 YM 8-61 ATLAS