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FOR OFFICE USE: ' -------------- --------------------------------- �/ Y __ ___ ___ff_-.t . _ - . APPLICATION FOR SANITATION PERMIT Permit No. ...../r0 -.�.. .... --------- _------------------------- (Complete in Duplicate) Date Issued ,1/ -------------°------------------------------------------- I 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. This application is made in compliance with County Ordinance No. 54,9.. / JOB ADDRESS AND LOCAT N--------±.'� � ?� - -'' 1 ........................................................ ------------------_ Owner's Name = - _ .. a-' -----_------ Phone.................................... Address '.. •--- f = = --------------------------------------------------------------------------- Contractor's Name. '------------------------------- ------ Phone................................... Installation will serve: Residence ?Cpartment House ❑ Commercial ❑ Trailer Court ❑ Molel ❑ Other ❑ Number of living units: /.... Number of bedrooms -___ Number of baths ___ . Lot size ....:�.?__ t�___.., �.. ...................... Water Supply: Public system p" Community system ❑ Private ❑ Depth To Water Tableft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam Clay Loam Clay ❑ Adobe❑ Hardpan C] Previous Application Made: (If yes,date___-----------------) No.❑ New Construction: Yesj No ❑ FHA/VA: Yes ❑ NI�Z TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tank: Distance from nearest well------ ""__Distance from foundation__14*..._..._..Material No. of compartments---------_f_____. ._. .� , Liquid depth....... ------- Disposal �Field: Distance from nearest well.--.- _._Distance from foundation..__ _.._`_.......Distance to nearest lot line.................. fffNumber of lines__________ _____ � _; _-._. _--__Length of each line.....__._._.� ...;......Width of trench.........:. `.`. Type of filter material._.. _____Depth of filter material..../'_`-..........Total length........ ........................ See age Pit: Distance to nearest well_._..I---_--_.-_-Distance f fo dation___.,`.:�_'_..Distance to nearest lot line... ------------- Number -----_.__..Number of pits____-/...__.______Lining material---it�_..Size: Diameter____.-:-;1_--_ --_-.-_ Depth------------- C sspool: 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 laws, and rules r ul s of the Sa Joaquin Local Health . (Signed)......................... . '�c� - �_ -----Owner and/or Contractor) --------------- By: Ti+le --•--------- . .. - (Plot plan, showing size of f, I ation of s sfe6 n re ation to wells, buildings, etc., can be placed on reverse side). FO A ENT US NLY APPLICATION ACCEP DATE 2 ------------------ REVIEWED BY------------------------------------ ------ DATE--------- BUILDING PERMIT ISSUED............. -------- ----------------------------- ......... DATE.----------- ---------------------------------------------------------------------------- ------ Alterations and/or recommendations:----------------------------------------------------------------------------------------------•---------------------------------•-•-- ------------------------ --------------------------------------------------------------------------- ---------------- ------------------------ -----------•------------•-------------•--------------------••----------------------•-------------- ----------------------------------------------------------------------------------------------------------------------- --------------------------•-•-........-----•-•----•-•-•---.....-----------------•---•-----------•--. ----------------------------------------------------------------------------------- ------------------------ -------- ------- ------ ------•---•-•-------•-•----------.................................................... ---------------•------------------------ --------------------------------------- ----------- --------- ----------- ------------------------- ----------------------------------------------------------------------------- FINAL INSPECTI BY:- ---- -- -- - - - ------- -. -- -------- - Date... ✓t—------------------------------ SAN JO QUIN L AL HEALTH DISTRICT f 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