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ICE USE: , __..._.- APPLICATION FOR SANITATION PERMIT Permit No. IX- ----- ----------- --- E � .. ---- f� ---------lq-" (Complete in Duplicate) 2 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. This application is made in compliance with County Ordinance No. 549. JOB ADDRESS AND LOCATION------..... = ---------........................... Owner's Name...... '. ___ PhoneC .4__.._�QT� ---- ------------------------------------------------------------------------------------- Address............... c ....... --- -- K Contractor's Name........................................... --....,R--------------------------------.................................. Phone................................... Installation will serve: Residence `t M---Apartment House ❑ Commercial ❑ Trailer Court F] Motel ❑ Other Number of living;unitsc __.[.._ umber of bedrooms 1,., Number of baths .....1_ Lot size ..A5.. IS.O-- -4 ------------------- Water Supply: Public system Community system E] Private E] Depth To Water Table ........ ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe[Hardpan ❑ Previous Application Made: (If yes,date--.-----------------) No ❑ New Construction: Yes ❑ No ❑ FHANA: Yes [nn No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic k: Distance from nearest well-----------------Distance from foundation....................Material................................................. �nrNo. of compartments---------------------_-Size-----------...------------------Liquid depth_..----------------------Capacity..---...---------•----- D'sposal Field- Distance from nearest well__ .-Distance from foundation.... Distance to nearest lot line--- _!._ Number of lines------------- -----�.__�_'_-�_.�Length of each line........_--_.s? , A/idth of trench...... Type of filter matenahl ,//:l4t�Depth of filter material_._.. _.._.....__Total length________________ _.] ,, Seepage Distance to nearest well------1/�-----Distance from fun dation__..__! Distance to nearest lot�e _ - ..-.. [ Number of pits---------`------ .Lining material_ ---Size: Diameter.-.._33.`......Depth-...--.. .......... v) 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--.------------------------------- --------------•---G--------------------------------------------•------------------------------..---------- M e4jo Remodelin and/or repairing (de ribe):-. s� . --------------------------------------------------------------------------------------------------------------------------------------------------•------------------------------------------------------------------------- ------------------------------------ -----------------------------------------------------------------------------------------------------------------------------------------------------•--------------------..-..-.....--- I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, S+ate laws, red rules end regulation f +he San Joaquin Local Health District. (Signed)---------- , ------------------------------------ -----------------------------------------(Owner and/or Contractor) By:........................................................----------------------------------------------------------------------------(riifle).--_------------------------- -- (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 BY--------- ------------------------------------------------------------- DATE------ of 43-----------_-------_-- REVIEWEDBY------------------------------------------------------------------------------------------------------------------------------ DATE------------------------------------------------------------ BUILDINGPERMIT ISSUED--------------------------------------------------------------...................................... DATE------------------------------------------------------------ Alterations and/or recommendations:------------------------------------------------------------------------------ --•--------------------------------------------•-------------••---. ' ---------------- -``'� 'C -------------sow'?'°---- pl'al<-K............................. ---:Z_---- .............••----•-......----...-•------------------------------------ ---------------- -------------------------- -------------------------------------- --•---•-----........... ................................. --------------------------- -----------"-_ ------------------�--✓-------------------------------------------------------------------------------------------------------------------------------..................... FINAL INSPECTION BY:. ........................ ------------------------- - � '2 7 Date. SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American street 300 Wort 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