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FO�OFIyIC E: ----------------------- -------- ---- -- ------------- APPLICATION FOR SANITATION PERMIT Permit Na. .- � ---- -------•---•---------------------------------- ° (Complete in Duplicate) -------.---------------------------------------------- .-_ This Permit Expires 1 Year From Date Issued Date Issued - 10-5-reo--n f Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein descrbed. This appl.icationFis made in compliance with County Ordinance No. 549, 5-7.Y.,E. ESS A7 � �.� �C(�'�-. .�'�l -------------------------------------- JOB ADDRESS A D LOCATIO I- !/� Owner's Na e... ------ ...... ........................... .•- Phone------------------------------------ Address ._.. .. . - --------------� --•------------------------------------------ -•-••--....-•-----•-•-....................................... Contractor's Name----- -------•------------------------•-------•-••--------------------------------------------------------------------------- Phone------------------................. Installation will serve: Residence [5—'Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: .__ Number of bedrooms 3__-- Number of baths-3___ Lot size ___Tg ...-.------••--•-•-•••••-•- , Water Supply: Public system ❑ Community system ❑ Private eDepth To Water Table 10 ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay Adobe C7 Hardpan ❑ Previous Application Made: (If yes,date--------.....-------) No New Construction: Yes eNo ❑ FHA/VA: Yes ❑ No [ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic a k: Distance:from nearest well_________________Distance from foundation.------------------Material------------------------------------------------- No. of compartments----------------------`._S•rze------_.:_.----------------_:---Liquid de th_-------••----------------Capacity - Disposa Field: Distance:from nears we€l.,r (_____Distance from foundation../0-___________Distance to nearest lot jlinel®a......... � Number of lines....... ---------------------Length of each line__4'_7.1-----------------_._..Width of trench. �'______.---_--------_..-- (1� Type of filter materi6.1�G�--------Depth of filter material___(�_._____--._Total length_-- ____________________________ 1� � r Seepage Pit: Distance to nearest well___ �4_____________Distan��from foundation `___Distance to nearest lot line_�0�...___._ Number of pits---- `�.___________Lining material/ -G _____-Size: Diameter___3s __.___--__-.Depth___: 4 ___________________ Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material.._.____-_-._________•------•_--_-_-_ ❑ Size: Diameter------------ -------------------------Dept h----------------------------------------------------Liquid Capacity..-------------------- ---gals. Privy: Distance from nearest well--------------_------------------------------------Distance from nearest building.__________-_________-__________--____._. ❑ Distance to nearest lot line---------------------------------------------------------------------------------------------------------------------------------------- Remodelingand/or repairing (describe):--------- --------------------------------------------•---•-•--•-•------------------------------ ------------------------------------_•----------------- ------------------------------------------------ ------------------•-------------------•---------------- ------------------------•--------•-------------------------•-•-----.-------------------------------- ................-------------------------------------------------••----------------------------------------------------------------------------------------------------------------------------- --------------------------- I hereby certify that I have prepared this application and thclf the work will be done in accordance with San Joaquin County ordinances, State laws, and rules an4syst f +he an Jo uin Local Health District. (Signed)------------------------------------------------------------------ -- - ---- ------------•--•----•----------- --- -------------------------------(Owner and/or Contractor) By:..................... -----------•-•--- --------------- --------------------•-•---------------=.....(Title)----------------- ---------------------- -.-.....----- --------- (Plot plan, showing size of lot, locatrelation to wells, buildings, etc., can be placed on reverse side). FOR DEPA TMENT USE ONLY ' APPLICATION ACCEPTED IBY------ _ DATE....-- r---~---6-----�3- ---- REVIEWED BY--------------------------•--------------------- ----------------- DATE BUILDINGPERMIT ISSUED-------------------------------------------------------------- ---•-••---------------------------- DATE-------------------------•---------------------------------- Alttons`and/or ret K r*mmaions . f � ------------------- r _07 ` rj ----------------------------------------------•--------•------------ -------------------------- ---------------------------------•-----------------------•----- ----- -•-----------•------------ ------------------------- -- -- -------------- .......................................... --------- -------------------------•-------•------------------------------------------------------------- FINAL INSPECTION BY:..;j Date---...;5�:..`.-257 _So_ ------------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 124 Sycamore Street 205 West 91h Sireet Stockton,California Lodi,California Manteca,California Tracy,California i6 E5 9 REVISED 8-59 2M 5-62 ATLAS