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-FOROFFICE USE: ----------------------1(ly---------------------------3c� APPLICATION FOR SANITATION PERMIT Permit No. (Complete in Duplicate) This Permit Expires 1 Year From Date Issued 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. JOB ADDRESS AND LOCATION Owner's Name-d, ---------•-------------- -- ----- Phone.................................... Address---•--••-.../1. � I - + ----------------••------------------------------------------------------•-•-••------------------ --••---------...--•--•----------------------- Contractor's Name--- __ .. . t--2------------------------------------------------------------------ -_-- Phone........K .'S- -7 Installation will serve: Residence Apartment House E] Commercial F] Trailer Court [-] Motel [3 Other 11f Number of living units: J.... Number of bedrooms J_ Number of baths __/---. Lot size __%XAy*__)__0.0.......... Water Supply. Public system L< Community system ❑ Private ❑ Depth To Water Table 10. ft. I Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe®' Hardpan ❑ "V i Previous Application Made: i!f yes,date--------------------) No i [ New Construction: Yes �V�o ❑ FHA/VA: Yes ❑ No � TYPE OF INSTALLATION AND SPECIFICATIONS: ft (No septic tank or cesspool permitted if public sewer is available within 200 feet.), Septic nk: Distance from nearest wel - . .Distance from foundation/0..._..______.MaterRal____1-�__.____.____ No. of compartments_________ _ Capacity--....____ _.._.. _._ Liquid depth__--. _._....r. Disposal Field: Distance from nearest well__-Distance from foundation_JoP_.1..--------Distance to nearest lot line._�.r_...._ [t Number of lines-----------w ______.__.....-Length of each line-------- r---_______-.Width of trench---------- /- _._--_---__ i Type of filter material _-Depth of filter material____$_______________Total length_____$_.1 ._______----__________..__.. i Seepage Pit: Distance to nearest well____- -----Distance from foundation_10.2---------Dista nce to nearest lot line_ ....... Number of pits___. ------1----------Lining material.-._ a ...size: Diameter3t?---------------Depth------------a.dn---------- I Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material__..___-_______________....___ ❑ Size: Diameter------------=------------- -----------Depth---------------------------------------------------Liquid Capacity............................gals. t Privy: Distance from nearest well_____________________ _-_.___-Distance from nearest building------------------------------------------ Cl Distance to nearest lot line Remodeling and/or repairing (describe):-----------------------------------------------_.. -------------------- ------------------------------•--_.----- -------------------------------------- --•- _ ----•------------•----------------------------------------------- -••--- - ----- . ,- ------------------•----------------•- --------------------------------------•----•• ---•-----•-----•---•--------- ------ I herebycertify that I have prepared this. a Ic on and JAaf the work will be done in accordance with San Joaquin County s ordinances, State laws, and rules and regulatio a San aquin Local Health District. (Signbd.)•*--------------- f _________________(Owner and/or Contractor) ! By;.........................--•-----------------•---------- ----- d {Title) (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., canplaced on reverse side). FOR DEPARTMENY,;USE ONLY APPLICATION ACCEPTED BY ---'- -- - -------------- DATE..---------- .- - ---------------------------------- REVIEWEDa'BY--------------------------------------------•-------------------------•----------------------------_---------------------- DATE-•------------------- BUILDINGPERMIT ISSUED--------------------------------------------•------------------------------------------------------ DATE AFFerations nd .or recommend ton --•--------------•- ----------------------------------------------------------- -•--------- --- -------------------•---------.-----------•-------------•---_----------- -----------------------------------I---------••---------- -------• ----------------------------....-----....--------•--------------- ---• -------------------- --------- -- x ------------------- -- i. FINAL INSPECTION BY:...... . ..-------�-�"- ------------------- Date-------------------- - --.k. .----••-•------------------ SAN JOAQUIN LOCAL HEALTH DISTRICT R 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 /��'�