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FOR OFFICE USE: . P,�Z Zo ------------------------------------------------------- APPLICATION FOR SANITATION PERMIT Permit No. ------- ------------------------------------------------ (Complete in Duplicate) a �-� _(� 3 This Permit Ex ires I Year From Date Issued 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. 5 ? i JOB ADDRESS AND LOCATION .__ . __ �� ---------------------- ------- --------- Owner's Name '---=-------- "� Phone. 7�a Address----�� - -------Q --- --- --------- Contractor's Name------------- - l -------------------------------------------------------------- ......................... Phone..---............................. Installation will serve: Residence ff Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: J..... Number of bedrooms _1.._- Number of baths /-_.--. Lot size --- a_' --- .3 Water Supply: Public system Community system. ElPrivate ❑ Depth To Water Table ._!4ft. 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 B---New Construction: Yes RKI�o ❑ FHA/VA: Yes B-INo ❑ TYPE. OF INSTALLATION AND SPECIFICATIONS: � (No septic tank or cesspool permitted if publics leer's available within 200 feet.) / . t/J Septic/Tank: Distance from nearest well _- ---------Distance from foundation---`9_r----------.Mater}al-. ---- ----- CB No. of compartments-------.---'2-----.----Size-----3A6-9--------Liquid dep. th_------------------Capacity- ` �._._. Disposal Field: Distance from nearest well_'_-'----------Distance from foundation-I9•------------Distance to nearest lot line._! ...... [ Number of lines------/.-_-._________-_______-____Length of each line_____---------------..,Width of trench-__- -'_"______________-_ Type of filter material'70C—ti_-----------Depth of filter materiall--r...............Total length------Stall........________________-- Seepage Pit: Distance to nearest well----------------------Distance from foundation....................Distance to nearest lot line................. Q ❑ Number of pits----------------------Lining material------------------ ---Size: Diameter---------------------- Dept h------------------..__-----.._._. Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material.........................._____-_-_-_ Size: Diameter--------------------------------------De th----------------------------------------------------Liuid Capacity gals. Privy: Distance from nearest well-----------------------------------------_-----__Distance from nearest building_--__...._________-______-_____________.. `4J ' ❑ Distance to nearest lot line------ --------------------------------------------------------•----------•--------------------------•---------------------------------------- Remodelingand/or repairing (describe) �-----------------•--�--•---•---•----------------..--------..--------------_----F--•------•----•------------------- ------------------------------------------•-----------•----------------- 3 � ---------C—)-r ----- 17 r.t2 .�. ---------- ------ --------------------------------------------------------------------------------------------------------- --------- ------ -----------------------------------I------------------------------------------------------ ----------------------------------------------------------------------------------------------------- hereby-certify that I have prepared this application nd that the ork will be done in accordance with San Joaquin County ordinances, State laws, and rules and regulations of A ' n aquin cal Health District. (Signed)------------- --••---------------------------•---------- - --------------- ----------- - •----- --------------------------------------------------(Owner and/or Contractor) B (Title)_ Y• (Plot plan, showing size of lot, location of system in r ation to Ifs, buildings, etc., can be placed on reverse side). FOR DEPAR MENT USE ONLY .Q APPLICATION ACCEPTED BY---------------------------------------------------------------------- --� �-r�- DATE.-------- ----------------------------------- REVIEWEDBY----------------------------------------------------------------- ---------------- --------------------------------------_ DATE_-•------------------------------•------- ---------------- BUILDING PERMIT ISSUED----------------------------------------------------- ------------------------ •---------- DATE----------------------------------------- Alterationsand/or recommendations:--------------------------------------------------------------------------------------------------------------------------------------------------------------- --------------------------------------------------------------------------------------------------------------------------------------------_.-------•-----------•-------------•--•----------------•------------------------- -•------------------- FINAL INS 710N BY -- :_________ Date._- -3 x3 SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 124 Sycamore Street 305 West 41h Street Stoddon,California Lodi,California Manteca,California Tracy,California E5 9 REVISED 8-59 2M 5-62 ATLAS I i