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FOR OFFICE USE: ------------------------ ----------------------------- � �Z APPLICATION FOR SANITATION PERMIT Permit No. .__.....,. ------ --------------------------------- ----•- (Complete in Duplicate) I ------------------------------------ . _ Date Issued ...._lI I This Permit Expires 1 Year From Date Issued Application is hereby made to the San IJoaquin Local Health District for a permit to construct and install the work herein described. This application is made in compliance'with County Ordinan - JOB ADDRESS AND LOCATION___-- ---_ ° - --- .: --•--------------- ------- Owner's Name---------- 'Y1 �� .� -------------------------------------- phone....•- Address `f 7`� - c. t -- -----------------------------------------........................... 1 _ ...,. - R 4 ` ---`----------------- Phone---------------------••------------ I Contractor's Name...-�------•----•�•--P--- -•------... .. -`_]-'••��Q!-�-4''----------------------•- •- Installation will serve: Residence. lApartment ouse ❑ Commercial ❑ Trailer Cour} ❑ Motel ❑ Other ❑ ° Number of living unit --------- Number of bedrooms � Number of'baths "" Lot size _.". G-----••------•••-•-•- r Water Supply: Publicl system Community system ❑ Private ❑, Depth To Water Tabieir Character of soil to a(depth of 3 feet-1Sand E] Gravel C] , Sandy Loam Clay Loam Clay ❑ Adobe j Hardpan ❑ F - No�' Previous Application Made: {If yes,date".._. I No ❑ New Construction: Yes No ❑ FHA/VA: Yes ❑ s TYPE OF INSTALLATION AND SPECIFICATIONS: ` t (No septic tank orµcesspool-permitted-if-public sewer+is aVailab`!e w"�tfiin 2'00 feet.} Septic Tank: Distance from. nearest well.-".eO...Distanice"'from foundation-_._e?�--------Materi` •••--- _--.-Ca aci -�,. „-"':" ,. - �• -c Liquid depth +�"� -----Size_ t No. of compartments""""".:'�{_" �� - "-�"�" P �""•'- Disposal Field: Distance from .11 11 +well./.-e o. -Distance from foundation--1¢---.._.-Distance to nearest lot linye �._"""_.... Number of lines_-"I__""3 Je --- `------'LengtKt4f each line-� ,40"e, .Width of trench--.--� ..-". --•--- Type of filter material.-> --------Depth of filter material-----Zer-----------Total length------.5a------------------------•-- Seepage Pit: Distance to nearest well..K1 Distance fr foundation....,0....__..Distance to nearest lot line---_./:1""""._ 3 Number of pits-",""""""---_"." __Lining material"__- -__"" ""�""- Size: Diameter-- - -- .........Depth.......Z1---- •---- Cesspool: Distance from nearest well-----------------Distance from foundation.--.----------------Lining material------------------------------.------ El Size: Diameter.__---------- -----------------Depth------------------------------------------------------Liuid Capacity-------------------------_-gals- Privy: Distance from nearestwell •---------------------Distance from nearest building------------------------------- ."•-•--. ❑ Distance to nearest lotjine-- ------ = _ f "r. I � � I Remodeling and/or repairing {describe):--------M---------•---•-------------- -------•--------------------------------------••------•-----------•----------•----------------..------... - l_!-----------------------------------------•-------•-----------•----------------------------------------•-------------- -----------------------"•.-•-- --•-$"""_""�.._ -----••-- --------------- ----------------------------------- -- - -- -••---------------•----••------- I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin ounty" ordinances, State laws, and rules and regulations of the San Joaquin Local Health District. r _ tractor) (Owner and/or Con (S• ned}-•-•---- ' (Piot plan. showing size of lot, location of system in relation to wells, buildings, etc., can he-+placed on re`brs�e side). I FOR DEPARTMENT ONLY APPLICATION ACCEP BY-- --- ----------- DATE i -----•-- . DATE------------------ - ------------------------------------ REVIEWED -----------------------•-----------REVlEWD BY - ------ ---- BUILDING PERMIT ISSUED-------------- ------------- -- --------------• DATE_------------------------ --------------------- ----------- Alterations and/or recommendations:----- ----------- ------------------------------------------------.----------------------••--------------------•-------------- --------•--------------------------•--•-•-- ` .......... ---------- --------- ----- -- --------11-------••----•-•-----------------------•-----•------------------------------------------ ----•----------•---- FINAL INSPECT! -" Date."../--- -- -- ------- -------- i AN JOA IN LOCAL HEALTH DISTRICT 130 South American Street 304 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,California Manteca,California Tracy,California ti ES 9 REVISED e•54 PM 5-62 ATLAS <Z:_