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FOR OFFIC USE . . APPLICATION FOR SANITATION PERMIT Permit No. ........��...... ------------------- --------------------------- ----------------------------- (Complete in Duplicate) ----------------- This Permit Expires 1 Year From Date Issued Date Issued ....... •'�'�r 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 Or ce No. 549. JOB ADDRESS 41L AT ----- ' ---------- - -------------------------------------------------------- Phone.... -----------------Owner's Namef- Address-- - $ 1 ----- --- ---' J ---- ---------------------•------------------------------ •--- - ---- - --,------ -- --G�---� - -- Contractor's Name-------------------------- --------------------------------- --------------------------------------- Phone d- Installation will serve: Residence IKApartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: ._ Number of bedrooms..?_-_ Number of baths ---l-- Lot size .-_1 Water Supply: Public system ❑ Community system ❑ Private P-151epth To Water Table 5- v. ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe Hardpan ❑ Previous Application Made: [if yes,date--------------------) No ❑ New Construction: Yes ❑ NoFHA/VA: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: 4k.1 ic tank or cesspool permitted if public sewer is available within 200 feet.) tiDistance from nearest well-----------------Distance from foundation--------------------Material------------------_----..........--._-----..... No. of compartments---------------------�.-Size-------------------------------Liquid de�th---•--------------------•-Capacity---•------------...`-- Disposal Fi Distance from nearest well--- _..._Distance from foundation./d---_----...Distance to nearest lot (line-----�..... Number of lines_____ __ Length of each line------------- _____--.Width of trench.__- ------------ ------ —` Type of filter material-St-8, Depth of filter material-_--.-.�S-�i-Total length----------------------yam. __-- Seepage Pit: Distance to nearest well----------------------Distance from foundation....................Distance to nearest lot line_....---_---__--_ r', ❑ C)i Number of pits----_----------------Lining material-.---------------------Size: Diameter----------------------- 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-------------------------------------------------------------------------------------------------------------•--••------------------•-------- Remodelingand/or repairing (describe)=---------------------- -----------------------------------•---------------------------••---------------•------------------------------••---------------- ---------------•--------------------- ----•----- ----------• ------------------ --------•-------•------------------------•--------------.--------------------------------------------------------------------------- I hereby 4 y that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinanc t azs,�Andrusend lations of the San Joaquin LocHealth District. (Signed)--- ----•---_-•------ ----------------- weer and/or Contractor) Ry:--------------------------------------------------------- - ------------ ------- -------Zii {Title) --------� ----------- ---------------- u (Plot plan, showing size of lot, location of sys em in relation to wellsdings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY-----C t -----------------------------•----------------------------•------- DATE-._1 _-! rZ-------------------------- REVIEWEDBY------------------------•-------------------- --------------------•----------------------------------------------------------- DATE--------------------------------------------------•-------- BUILDINGPERMIT ISSUED--------------------------------------.-...-•-----------------_•---------..-.-•-------------------- DATE-----------------------------------------------------••----- Alterationsand/or recommendations------- ----------------•-----------------------------•--•-----------------------------••-----...------------•--------•-------------------------------------- z...---------1 -------- lki-S p =- Q ----`------- .- ..as Zy ........ ,d c i�. �► ►- � +� . -�- ----------------------------------- -----------------------------------------------------� _ ------------ FINAL INSPECTION BY:.-------•-'----- -- ---------- -- ---- •-------------•----- Date ^ale--'-I'-�--------- - ----------------- - SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Srreet 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,California Manteca,Californla Tracy,California ES 9 REVISED 8-59 2M 5-62 ATLAS