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FOROFFICE USF: ---� c - - .. - ----- -------------- --- - -- - __ - APPLICATION FOR SANITATION PERMIT Permit No. ....... �..` f - -- (Complete in Duplicate) -------------- This Permit Ex ires 1 Year From Date Issued i.. �� l� ------------- -------- Date Issued .... 4 is hereby made to the San-Joaquin Local Healfh District for a permit to construct and install the work herein described.. . This application is made in complian 6e'liounty Ordinance No JOB ADDRESS ANR LOCATION...;bl_----•!/U j L. - •--- ------I------------------ ' Owner's Na �... --------------- Phone.--------------------• Address....... : - r Contractor's Name--.------ ?' --------------------------------------•--------•----------- ---.:..---• ------------------------------------------ Phone----------------------------------- Installation will serve: Residence Apartment House ❑ Commercial.E] Trailer Court ❑ Motel ❑ Ofher ❑ Number of living units: -----I_ Number of bedrooms .- -. Number of baths -- -Lot size / -60)e�:ZJ-�Z-_•__--_.____-- Wafer Supply: Public system ❑ Community system ❑ Private [Depth TO Water Table _P90W ..:Character of soil to a depth of 3 feet: Sand ❑ Grave! ❑ Sandy Loam ❑ CEay Loam ❑ Clay ❑ Adoberdpan ❑ l TYPE us Application Made: (If yes,date------------ ------I No New Construction: Yes No FHA A: Yes Previ � ❑ FHA/ 2T`ao ❑ OF INSTALLATION AND SPECIFICATIONS: "... (No septic tank or cesspool p;rmi#ed if public sewer is available within 200 feet.) I i �, - � Septic T Distance from nearest well-/490..........Distance from foundation._-l-A---•------.M terial--a.c4x . No. of compartmi nts---------2-------`.-..-Size.._7A_-�J---------Liquid depth.-- ------Capacity IT Disposal Field: Distance from nearest well./PA--------Distance from foundation.-"Alf•+�...Distance to nearest lot line_-� --- [ Number of lines.-'----.- - -------------.,_Length of each line...Tllf-,_---/__...-_.-.Width of trench--.:Z.-y �•- Type of filter material.......--._7&_4/C_Depth of filter material-l-r----_-_---._Total length----65. --------------------y---•- Seepage Pit: Distance to nearest well-_J-04----..----_Distance from foundation�ir�_......-.__. ' fence to nearest lot line--- Number of pits----'---- ------Lining material-rff _5±�y__Size: Diameter_- -�--------Depth--------- ................. Cesspool: Distance from nearest well-----------------Distance from foundation---_---------------.Lining material---_.----...------- -__...--__-...:_: ❑ Size: Diameter ----------Depth•---------------------------------------------------Liquid Capacity----•-----------------------gals. Priv 1 y Distance from nearest well-----------------------------------------.-------Distance fiom nearest building----------.-_-----------_- ' ❑ Distance to nearest lot line----- Remodeling and/or repairing (descriL?e)----------------------------__ -------•-------------------•-----•--------------•----------•� --------- 4 + •----••_____________-_-•__... -_-_----__-•-------------------------------------------- ----------------------------------------------------- ------ I I hereby certify that I have prepared this a lica�ton„end that the work will be-done in accordance with San Joaquin County ordinances, State laws, and rules and regulatio -oft San Joa uin Local Health District. (Signed)....----------------••------------------,--.-.-...--- ------ (Owner and/or Contractor) ------- ------------------------- --- ._... ------__---------------•-• ----'--- --- Title (Plof plan, showing size of lot, locaf,on' of s tem in relation o wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY--------C1� __ ___________ ! ------------------------------••-•--------- DATE-- �.-.fc- . REVIEWED BY -----•------------ - ----- DATE..---------•-----••--••--------- ---- - NG PERMIT ISSUED, I DATE -----•------------------••-------------------- y ns and/or �In ....-- fin-- --------- eraf ----------------------------------------------------------- ---•--••------ -------•----------.- io I . -!•...................-------------------_----------------------- FINAL INSPECTION BY:---- -� -- ` Date---- --- g_ SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,California Mantecar California Tracy,California E5 9 REVISED 8.59 2M 5-62 ATLAS i 4 .._ 2 7