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FOR OFFICE USE: -?6 ------------- ----------------- ------------------------- ----- - ------------------------------ p� APPLICATION FOR SANITATION PERMIT Permit No. .�`✓..Q.. ------ --- - (Complete in Duplicate) Z Date Issued -----------------------__---- -- ----- -:-_-_._-_ I This Permit Expires 1 Year From Date Issued 94*ry to ......�._. __�� Application is hereby made to the San Joaquin Local Health District for a permit to construct an6 install the work herein described. This application is made in compliance with County Ordinance No. 549. WIL JOB ADDRESS AND LOCATION.. y-_ 1__w! 'd' _ 'f ?Pt!..___.�!R.._3' __. '_ '2_-- -_-•---•__•-• Owner's Name---- - --- ------------------------------------------------------------------------ ------------------ Phone---------•--•----•-•-•••...•=•...••- Address.......................... -�� 1VjjZ -- ---� -•-----------••-------•- ContractorsName- ------------------------------------------------------------------------------------------------------------------------ Phone................................... Installation will serve: Residence 4j Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: _I!..... Number of bedrooms Ji--- Number of baths _3____ Lot size ...3-----01c'-`#/................................... Water Supply: Public system ❑ Community system ❑ Private ® Depth To Water Table ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam Z Clay Loam ❑ Clay ❑ Adobe❑ Hardpan ❑ Previous Application Made: (If yes,date--------------------) No ji� New Construction: Yes W No ❑ FHA/VA: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) �c Septic Tank: Distance from nearest w II__ __11'-------Distanc fr� M foundation____!Q!._________. aterial_�!'�-!�-........................... 02'/a No. of compartments ►Size=/ 1` 5 ---Liquid depth_•.•..y-----------------Capacity ,....-•-•--- Disposal Field: Distance from nearest well-S�7------._Distance from foundation__ �____._-___.Distance to nearest lot line...r......... ba Number of lines_____a� ________Length of each line____ �"d_'..............Width of trench---.��i.'!___-_.________________ Type of filter materia ---Depth of filter material------1.9-----------Total length...A'6V-=----•-•-------------••--.. Seepage Pit: Distance to nearest well----------------------Distance from foundation....................Distance to nearest lot line_._.............. ❑ Number of pits______________________Lining material---------•------------.Size: Diameter____-_________-__.-____"Depth................................. 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 (describe):---...................................................................................................................................................... ----------•------------------------------------------------------------------------------------------------•--------------------------------------------------------------------------•--------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ -----------------------------------------------------------•------------------------------------------------------------------------------------------------------------------------------------------------------- I hereby certify that I have prepared this application_and that the work will be done in accordance with San Joaquin County ordinances, State la s, and rules and regulations oft n Joaquin Local Health District. (Signed) '= -•-•- +','� = -------------------------------------------------------(Owner and/or Contractor) By:...... --•---------------------•--__._-_----- ------------------------------------------------------------------------(Title)----------------------------------------- --------- (Plot plan, showing size of lot,,location of system in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED B -- ----------------------------------------------------------- DATE----c `' 'Z'!k -------------•------------- REVIEWED BY------------------------------------------------------------------------------------------------------------------------------ DATE---•----------------•--------------•---------------- •------- BUILDINGPERMIT ISSUED------------------------------------------------------------------._.----------•--- .._------ DATE............................................................. Alterationsand/or recommendations:-----•-------------------------------------------------------------•--------------------------•------------------------•--------------------------------------- _...---•----•-•--•--•.._•--------•----------------- ---------------------------------- --••-- ------------•----•--•------•-•------•----•••-..-••---------------•-•----••--•----••••------------------•-------------•--------- •-•••--•-----•----•-------•-••-•-•----••-••--•--------•---------------------- ----------------------------------------••-•-••-•--------••-•-•-----._.__._._•••-•-----•-•---••------•------•-----------•----••--••--_...... .................................... ----------------------------------------------------------------------------------•----•--------•---•-----•-----------••----•--••-•-•-•---•------•-----._..-•••---------••----••-- ----------------------------------------------------------------------------- ----------------------- --------------------------------------------•--------------------.....................--------------- -------........ FINAL INSPECTION BY: ----------------- Date-2- ......................... --------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 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 r