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FUROFFICE USE: ----- l -----:----. APPLICATION FOR SANITATION PERMIT Permit No. ....1_..��f : ------------------------------------------- J ------------------------------------------------------ (Complete in Duplicate) / --------------------------------------------------------- This permit Expires 1 Year From Date Issued Date Issued -_____, _ �- /I Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described f This application is made in compliance with County Ordin rete No. 549. 11. 7 ... �9 JOB ADDRESS A LOCATIO 1'4e2.0 _-- •-- _: -� �_ Owner's Name----- ---------- ��-- -----•-------- --- ' ----------- � ---------- - --- ----------------- Phone.................................... V u Address---- ----- ------------ ....__..e.................... P1.. ......f.? Contractor's Name- "SL-- --- . ---t----- - -L--' ------------------------------------------- Phone.............•--------------------- � Installation will serve: -Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel [3 Other ❑ Number of living units: J___ Number of bedrooms .q. Number f baths _ Lot size __ F_ ° ____________________________________ Water Supply: Public system E] Community system [I Private epth To Water Table, __ ft. haracter of soil to a depth of 3 feet: Sand [-] Gravel E] Sandy Loam [Clay Loam ❑ Clay ❑ Adobe❑ Hardpan ❑ t Previous Application Made: (If yes,date--------------------)` No [XI —New Construction: Yes JR] No ❑ FHA/VA: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) f Septic ank: Distance from nearest well.:-,5_&_-- Dista ce, from foundation----1.0___.-___.Material___ - : '_ _ Size I f� No. of compartments------ __1_Q___ s Li uid de th__-- Capacity_ __ Dispos field: Distance from nearest well_._._ i?.._Distance from foundation__- �1------------Distance to nearest lot I ne.---------------_---- Number of lines_______.._.------- � , Length of;each line.._..___6.l0_-_`._..___..Width of trench.___57_________________________ g Type af.filter maternal:_. �t�L ._.__Depth of,.filter.material___--� _.._.__Total, length____2_ 16___'`_____.__--__---__-- n >, 11 Seepage Pit: Distance to nearest well----------------------Distance from foundation--------------------Distance to nearest lot line----------------- ❑ Number of pits----------------------Lining material------- :--c --t----Size: 0 F1 '1 Cesspool: Distance from nearest well.................Distance from foundation--------------------Lining material-___._._________________.______._._-. ❑ Size: Diameter--------------------------------------Depth---------------------------=-_----------------------Liquid Capacity----------------------------gals. ❑ Distance to nearest lot line_..._�__..�____________.____-__-:_-__-_-,:-- Dis#ance�from,.nearest building.�•_________________________________.___.� Privy: Distancefrom nearest well ____________-_________------------ F._ -----------------------------------------------•--------•-•-----=-----••-------------------- Remodeling and/or repairing (describe)____________________ _ In ___________.___________-_-_________,_ ______________--___-----.____ -_...._._-_._-_ _____ __ ....................... ------•--- T. -----•------`----------- = 1 hereby certify that I have prepared this application and that the work will be done n accordance with San Joaquin County ordinances, State law and rules and regulations of the San Joaquin Local Health District. - (Si ned i 9 )-----•-•--:• --------- -=------------ - - ---------- - - -- --- -------•-------------------•--•-----•--•-- ------------ d/or Contractor By:------------- -- -• ••-•--- - ---------k'------- ---=---E---- ---•- trifle)---------------------------------------------------------------- (Plot plan, showing size of lot, location of system in relation to Ills, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY-- ---------------- DATE_. 71_�__.__________-----•------------ REVIEWEDBY------------------------------------------------------------------------------------------------------------------------------- DATE------------------------------------------------------------ BUILDINGPERMIT ISSUED----------------------------------------....-•------------------------------------------------------- DATE--------------------------------------------- ............... Alterationsand/or recommendations----------------------------------------------------------••------------------------------------••------••----••------------.....-----•------------------------- FINAL INSPECTION BY:. ---- ------ --------------------------------------- Date_/Z_ �h_:K�------ ------------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT , 130 South American Street 300 West Oak street 124 Sycamore Street 205 West 91h Street Stockton,California Lodi,California Manteca,California Tracy,California ES 9 REVISED 5-59 2M 5-62 ATLAS t