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FOR OFFICE USE: r r •. ------4 2tt V -_._...____°_--- APPLICATION FOR SANITATION PERMIT Permit No. ........ -------------------------------------------------------- (Complete in Duplicate) Date Issued ...:..0T—..3-.(-13 -- ------------------------------------ ---_..____.___.___ This Permit Expires 1 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.................................LOCATION------ .._; ""......•---..._..--•.. .........................•------•---- ---- - ------ Owner's Name. , /l!..... ----- Phone----------------_........... Address.........------•----. --- -------- ---- ------------------------------------------ ................................. A Contractor's Name---------------- •• ---------------------------------------------------------•---...._.-..---------. Phone........-i 5...7 .......... Installation will serve: Residence M' Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: __¢____ Number of bedrooms .3---- Number of baths 1.--. Lot size _.1dA_kZZ ................................ Water Supply: Public system ❑ Community system ❑ Private ❑ Depth To Water Table 9. ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe Hardpan ❑ "X Previous Application Made: (If yes,date----------------- ---) No L!} New Construction: Yes ❑ No 2!r�FHA/VA: Yes ❑ No TYPE OF INSTALLATION AND SPECIFICATIONS: a (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic ��A��:/_�,�,_�, Distance from nearest well_________________Distance from foundation--------------------Material------------------------------------------------- - .�(/`Q"'"- -f No. of compartments-----------------------•-Size-------------------------------Liquid depth--•-----•-----------------Capacity----------------------- Disposal Field- Distance from nearest well_________________Distance from foundation....................Distance to nearest lot line................. ❑ f Number of lines------------------ ----._Length of each line------------------------------Width of french----------------------------------- Type of filter material_________________________Depth of filter material-----------------------Total length------------------------------------------ Seepage Pit: Distance to nearest well_.laa_f__________Distanc, om found � ation_� ...' 1 ........Distance to nearest lot line.-_` _.._..._.. Number of pits._/-_________________Lining mate .....Size: Diameter---3!1;.,----------Depth----- .................. 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 -------------------------•--•------------------------------ I hereby 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 r ulati s of the an Joaquin Local Health District. (Signed) ________________________ Owner and/or Contractor BY:------------------------------------ ------- -------------------- ----------------------------------------------------------_(Title)--------------------------------------------------------------- t plan, showing size of lot, locatio of system n relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMEN USE ONLY APPLICATION ACCEPTED BY--------- .a -- -- -- --- ---------------------------------------- DATE- �� ----�� -------------------------- REVIEWEDBY-------------------------------------------- --._.- DATE------------------------------------------------------------ BUILDING PERMIT ISSUED - ------ ------------------------------ D/4TE --- ---- Alterations and/or recommendations:--.- i ..................................................•-•----._....--•---- _ --------- -------------- •---------------------------------------------------- - --�------------------------------•-----••------•---- ...............--------------------- - -------------------------------------------- -—--—--- -- --------- --- --------------------- I-- ------------------------- FINAL INSPECTION BY:.-- ------ Date----777:=Z.--j�..�.. ...........•---------..-......._.............. SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 Wert Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,California Manteca,California Tracy,California ES 9 REVISED 8-59 2M 5-62 ATLAS r