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FO OFF1C U, " 4 �3 �� Permit No. .. .........APPLICATION FOR SANITATION PERM ___________ _______ {Complete in Duplicate) -------------------------------- -------------------- -------------------------- Date Issued_ _______________ This Permit Expires 1 Year From Date Issued Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described. Application is made in compli e with County Ordinance No. 549. .1-4 'JOB ADDRESS D OCATIO t � Owner's e.---------- -------- Phone-----------•--------------••-------- 9 Address..._._... ; t ------ -------- --r--4----- } Phone_. 71.... , Installatiion will serve: ' Residence artment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: ___ Number of bedrooms _umber of baths ./___ Lot size ----•-- t ------_-- Water Supply: Public system ❑ Community system ❑ Private P-15'e"pth To Water Tabled;!�) ft. ravel Sand Loam ❑ Clay Loam ❑ Clay ❑ Adobe Hardpan ❑ Character of soil to a depth of 3 feet: Sand ❑ G ❑ Y Previous. Application Made: (if yes,date-------_-----------_) No ❑ New Construction: Yes ❑ No FHA/VA: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: j?o septic tank or cesspool permitted if public sewer is available within 200 feet.) eptic fan is ance from nearest well---------- Distance from foundation__._________.______.Material____________--.____________-----_______________- , No. of compartments----------- ------- ---Size--------------------------------Liquid depth--------- Capacity.. e-" is osaI Distance from nearest well-._ __Q_____.-Distance from foundatio ld___._-Distance to nearest lot line._s _�Q.__ ..� Number of lines____ ______________Length of each line__�0__ ...........Width of trench.___-_Yoe,` i- ------------Total length-----•----------------• ��--- -- �.4}�.� Type of filter matenaL_ __ Depth of filter matenal.--�_ ._ Seepage Pit: Distance to Weare t ell. VQ'0-12--________Distant rom f undation________ _ ____Distance to nearest lot line-- .� /f r Number of pits- ---- - ---Lining material , -----Size: Diameter__s ,J ___..____Depth__ .5�•••----- ------ Cesspool: Distance from nearest well-----------------Dis.ance from foundation--------------------Lining material------------------------------------- Size: Diameter--------------------------- ----------Depth----------------------------------------------------Liquid Capacity-------------------------- Privy Distance from nearest well----------------------------------- ----- -------Distance from nearest building--------.------•-----------------•-------. ❑ Distance to nearest lotline------------------------------------------------ ---------------------------------•-------------------------•-------- Remodeling and/or repairing (describe)--------- ------------- ---------------------•--------•---------•--------------•----------------- --------------------------------___------------------- ----------------I.................. ----------_--•--•-------------------------•---------------•-----•--------••--------- - ------••--•--- ----------- ------ I hereby -- f-- that I have prepared thi a p'cation and that a work Il be done in accordant with San Joaquin County ordinances, a aws. and ru s and regulations f the San quin Local ealth District. (signed- -- - -- ---• ------••- ---------------------------------------{ 4�w Contractor) ------ - Title By%_------------ ------------•••-----------------•--- - (Plot plan, showing size of lot, location of system in relati to wells, build' s, etc., can be placed an reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY------!Z__ c-g----------------------------------------------------------------- DATE----- -----•--------------------- REVIEWEDBY------------------------ ---------------------- -------------------- DATE---------------------------------------•------------------- BUILDINGPERMIT ISSUED---------------------------------- --------------••----------- DATE-------------------------------------------- ---------------- Alterations and/or recommendations:� ----------------•-------------------•------- --- ----------------•-----•-••------___--------•----•--•---••--•-------------•-•----- - -•-------------- 1 `_"_. .--•--•-- i----- �Vi•�ir.i:� �.t. ---`-------- -� C-Nps. C..._� _c.je, ..... ... FI NAL INSPECTION BY:. --- -- Date--- = -•--------------------------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 Wast Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,California Manteca,California Tracy,California ES 9 REVISED 8-59 2M 5-b2 ATLAS