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FOR OFFICE USE: I ___.--.-- -� _ APPLICATION FOR SANITATION PERM17 Permit No. .__.�.`............- -------------- -- -- ----- - -� -`- --h-r'7 (Complete in Duplicate) (, --.___-._ This Permit Expires 1 Year From Date Issued Date Issued ----------------------- Application _____________________Application is hereby made to the San Joaquin Local Health District for a permit to con eruct and install the work herein described. This application is made in compliance with County Ordinance No. 549. MOM JOB DRESS AND LOCATION---: - -- --- ---------/ __ ,---- ---: -r i 1 d Q.C..-- h70-21 Owner's Name------ .. .` =� =` `-' = Phone------------------------------------ - ----•- Address-----•----------- -%t-- =---------- ---- Contractor's Name •-------••------ -----------7�---------------- ------------ ------------------------------------------------. Phone................................... Installation will serve: Residence [g"'Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: ---V. Number of bedrooms Number of baths --Z_-- Lot size __.- - -__________________________ Water Supply: Public system ❑ Community system ❑ Private 04—Depth To Water Table &?ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel I❑ -iSandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe Hardpan El Previous.Application Made: (If yes,date-----------------;__} No New Construction: Yes eNo ❑ FHA/VA: Yes PT'No ❑ TYPE OF INSTALLATION AND SPiCIFICATIONSc (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tank: Distance from nearest weII�A---_-_Distance from foundation-/d!----------.Material---- ------------------------------------- No. of compartments------2--------- ----Size_-__ :-3,?�_�',t T.Liquid depth_ _9------------------Capacity____VAP = Dispos Field: Distance from nearest well._--?!;----Distance from foundation.10!!........Distance to nearest lot line 4�....-____- ' Number of lines-il --------------------Length of each line--�4 _----------------Width of trench.----2,..�-'------------_----- Type of filter mate rial-'A�_!;��-------Depth of filter material---f-k...........Total length.-.-.--.� ------ - ------ See a Pit: Distance to nearest well.-/bb-- --_----Distanc m foundation-----/Q/-_-_.Distance to nearest lot line--- Number of pits__'______.__--Lining material o-� ----Size: Diameter-_,-„•?- .......Dept h---------X17--------------_ 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 (describei--------------------------------------------------------------------------------------.......-----------------------------------••------ :::._--- ............. --------------------------------- --------------------------•----••---•------------ ----------- ---•-----------------------------•----------------------------------------------------------------------•---•-------- r --------------------------------------------------------------------------------------------------------------*--------------------------------------------------------------------*------------------------------------------ ----------• ------•-•-------------------------------------------------------------•-•--------------------_---------------------•---•----•----------------------------------- A ' 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 regulations of the San Joaquin Local Health District. (Signed)---------:---------------------•-------------•--l---------------------- - ---- ------------------------------------------------------------(Owner and/or Contractor) By:-------------------------------------------- --------- -- -------------------- ----•--------------•----------•.(r+le) :-..-...................... (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be,placed on reverse side). i FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY-.--"---+ -- --------- --- ------------------------ DATE_...... ==z�z- m------------------. REVIEWEDBY--------------------- ----- --- - ---- ---------- -----------•--------------------------------------------- DATE----------------_------------ ----_---••------------------ BUILDING PERMIT ISSUED............... y------ ----------- --------------------------------------- DATE------------------------------------------ Alterations and/or recommendations!------ ------ -•----------G-:-__ .. .--_G_. ------------•-1--------- ------ ---•----- - -------------------------------------------------------------------------------------- i -- ••---------- r ( ---------------------- ------I--------- ................I'------------ ------------•--•----•------•-------•------- ------- ---------------------------------------------------..................... ---------------- k FINAL INSPECTION BY:- - Date v " .- yam. SAN JOAQUIN LOCAL HEALTH DISTRICT II 130 South American Street 300 West Oak Street 124 Sycamore Street 205 West 9th Street ; Stockton,California Lodi,California Manteca,California Tracy,California li E5 9 REVISED 8-59 2M 5-6 ATLAS - r