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FOROFFICE USE: -----------------------e---- ----------------- --------- ---------------------------- -I-------------------------- APPLICATION FOR it No. d_3 R'SANITATION PERMIT Perm ................... ------------------------- ---- --------------------- (Complete in Duplicate) ------------------ -------------- ------------- This Permit Expires IDate Issued Year From Date Issued Application is hereby made to the San Joaquin Local Heal+h District for a permit to construct and install the work he This application is made in compliance with County Ordinance No. S49. ADDRESS AND LOCATION- Owner's Name-----U411 ---------- ------------------------------------------------ ---------------- --------------------------- Phone--------------------............... Address..---- -------------------•---- ------------------------•.............. Contractor's Name----------- . ..... �-------11.1------------------------ .........-- hone................................... Installation will serve: Residence n/Apartment House E] Commercial [I Trailer Court 0 Motel [I Other E] Number of living units. Number of bedroom s --- Number of baths __/--- Lot size ---- Water Supply: Public system E] Community system F] Private Rr--D'epth -ro Water Table -------- ft. Ej Character of soil to a depth of 3 feet: Sand ❑ Gravel [] Sandy Loam UR" Clay Loam ❑ Clay ❑ ' C]Adobe Hardpan El Previous Application Made: (if yes,date___._- .----_._ ._)- -- NoO New Construction:-Yes No 0 FHA/VA: Yes [I No Ell k� TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tank: Distance from nearest well---_------------Distance from founclati n------------------Material------------------------ EiNo. of compartments---------------------- t o___ :. -_: . ---------------- ----Size..----------------------------...Liquid depth----------------- ------Ca pacify----------------- Disposal Field: Distance from nearest well-_____46:_�Disfance from fovndation__./__,D---- ...Distance to nearest lot line-_-S..... Number of lines---------j----------------------Length of each line-----tf 4---------------- Width of trench-------?........------------------ Type of filter material-------------------__--Depth of filter mafbrial_---------------------Total-.length--------------------------------------- Seepage Pit: Distance to nearest well----------------------Distan"ce fro "mNfounclation--------------------Distance to nearest lot line.______......._.. El Number of pits------------------771ining_rnatdrial.'__`------ ------------Size:'D iameter.-.. -----------Depth--------- --------------------- Cesspool: Distance from nearest well:7n-----------151stance from foundation_________ ______Lining material_-_._____.-_-_--_-.._Size: Diameter---------------------------- . .......Depth"- --------------------------- Li'uid Capacity_---------------------- Privy: Distance from nearest well------ 0 ---gals. --------------Distance from nearest building______-_---_________...___------ ....................................... I ❑ Distance to nearest lot line---------------- ---------------------------------------------------- Re �an �or repairing (describe):------------------------ ------------------------------------ --—-------— -- ---- ---- ---- .... ------------------------............ ---------------------------------------------I—'-------------------------------------------------------------------------------- ---------------------------------------------------- I --------------------------------------------------------------------...--------------------------------------------------------------:._--------------------------------------------------------------------------- ---------------------------------------------------------------------------------------------------------I----------------------i-------i------------------------------------------------------------------------------- I hereby certify that I have prepared this application and that the work will b; done in accordance with San Joaquin County ordinances, State la <ad rules and regulations of the San Joaquin Local Health District. (Signed)--------•------ -------- ------------- ---------------------------------------(Owner and/or Contractor) By:,------- -%.t___=`--`--------------(Title)------------------------------------------ ---------- ---- •-- ----- (Plot plan, showing size of lot, location of system in relati n to wells, buildings,'etc., can be placed on reverse'side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY---- REVIEWEDBY----------------------------------------- -------------------------------------------------------- i--------------------.... DATE-------- ----- BUILDINGPERMIT ISSUED-------------------------------------------------------------------_---------;---------------I•------ DATE.-_-'.... Alterations and/or recommend'afiorts:---------- ------------------------ --------------------------------------------------- ---------I------------- --------- --------------------I---------------------------------------------------------------------------------------------------------------- ..........I-------------------------------------------------------------------------------------------------- -7 7--;---------------------------------------- -------------------------------------•----------•---- .................... ------------------- .................... ----------------- ------------------------------------------------------------------ ..4�---------------------------------------------------------------- -------_--------_ ---------- ----------------------_1-------------_ ------------------------------------------------------------------------ ------------------- ------------------------------------- -----------------7------------------- FINAL INSPECTION BY:--- -------_- ---------- Date----- -2------------------ SAN JOAQUIN LOCAL HEALTH DISTRICT t 130 South American Street 300 West 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