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FOR OFFICE USE: ---------------- } 'APPLICATION FOR SANITATION PERMIT Permit No. r --------------------------------------------------------- (Complete in Duplicate) J iThis Permit Expires 1 Year From Date Issued Date Issued ____ !.. .....�3 s Application is hereby made to the San Joaquin Local Heal+h 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------------ _. ;I _V--- -- ---- Phone -- IP Address.........-•--___-- --------------- ------------------.--------------------------------------------------- Contractor's Name--------------.............................................. -- ------------------------------------------------------------- Phone................................... Installa+ion will serve: Residence Apartment House Commercial Trailer Court Motel t P ❑ ❑ ❑ ❑ Other ❑ Number of living units: ._ -- Number of bedrooms _ __- Number of baths 4 Lot size ....... ---�C=�+! _` __. Water Supply: Public system ( Community system ❑ Private ❑ Depth To Water Table -?_-.'."ft. Character of soil to a depth of 3 feet:I Sand E] Gravel.❑ dandy Loam ❑ Clay Loam jR Clay ❑ Adobe ❑ Hardpan ❑ Previous Application Made: (If yes,date__--/�- - ---) No ❑ New Construction: Yes ❑ No ®( FHA/VA: Yes ❑ No TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool pe4nitted if public sewer is available within 200 feet.) Septic Tank: Distance from nearest well_________________Distance from foundation____-�.4.......Material....__-_______.__.-.._------------ No. of compartments-•---------- __--...Size°.-- ,,f., Liquid depth---------if!�_---------Cap acity..-------- ..� Disposal Field: Distance from nearest well----.-_______Distance from foundation...____ ___.Distance to nearest lot line-------;c _ Number of lines________________ --_ Length of each line------------xS^_ '------Width of french.._____________.._--�___ Type of filter maf,erial..._ Depth of filter material_-_- `' Total length. 4�U 1 t Seepage-Pit: 'Distance to nearest well' ------------------Distance-from foundation....................Distance to nearest lot line-----.___________ ❑ Number of pits---- --' '-- .----Lining material---- -----------------Size: Diameter-----------___.__.-.j..,Depth------.---.---------..----- Cesspool: Distance from nearest well-----------------Distance from foundation-------------------Linirig.material_- _____-___-___-__-.--_____-_._.. ElSize: Diameter - Depth------- _------------------------------------------.Liquid Capacity----------------------------gals. Privy: Distance from nearest well--------------__-------------------I------------Distance from nearest building------------------------------------------ F1 Distance to neare4 lot line------------------------------------III---•------------------ I - Remodeling and/or repairing (descrili'): f M1 - ''i` .` _ �- A a 'e r I hereby certify that I have prepa7ed'this application and that the work will be done in accordance with San Joaquin County ordinances, State laws, and rules andiiegulations of�he San Joaquin Local e lth%Districf., F :-- - ( (Signed)- -- ---el- ---' - -------- -- ------ -- - ------------------------.---------------- --: • • ______________Owner and/or Contractor) - BY= ....................... ------------------- ----------------------•--•-------------------- == -inti- ----------------------------------- ............. (Plot plan, showing size of lot, location'!of system in relation to wells, buildings, etc., ean'be placed on reverse side). _ 11 R DEPARTMENT USE ONLY APPLICATION ACCEPTED BY------A?�?--- ------------ DATE-------y '- REVIEWEDBY----------------------------------------------------------------------------------------- _._:.... .__..DATE---------------•----........ BUILDINGPERMIT ISSUED--------------------------------------------------------------_-------_---------------•----------- DATE----------------------------------------------------- Alterations and/or recommend'afions:---I---------------------------------------------------------------------------------•--•--------------- 1 ----------------------------..... ----------------------.-•---------------•-------------------------------•-•-------------•- ,i --------------• -•-------•-------------------------•• ------------------------------------ -------•--------------------•-•----•----------•--••--•-•------ --•--------••-----_--------•.----•-------------- -----------------------------------• -------------------------------- ------- •-------------------------------------------------•------------------------------------------------------------------------------------ ------------------- ........ . - FINAL INSPECTION BY:... ._ = Date----------- a SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 Weil Oak Street 124 Sycamore Street 205 west 91h Street Stockton,California Lodi,California Manteca,California Tracy,California ES 9 REVISED 8.59 EM 5-62 ATLAS