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FOR OFFI USS: 931 b -- I-_-__ APPLICATION FOR SANITATION PERMIT Permit No. -- ----- ----------------------------- (Complete in Duplica+e) / ------------------ -------------------- --- -- This Permit Expires 1 Year From Date Issued Date issued ..!h............. 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 AN9 LO TION.-I__Zo-rv—. 297 Z, i ` _•---_- ---------------•-•------•--------- Owner's Name---- --------------------- Phone.................................... Address { - --------------••---•--------------------------------------------- ---------------- ................................ Contractor's Name----- - --------•`---- `� ----------------••-•----------------------•-•---•-----------------------------------.-----•--- Phone................................... Installation will serve: Residence Ur"Ipartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: __ - Number of bedrooms _'V--_ Number of baths _.2, Lot size ....................... Water Supply: Public system Community system ❑ Private ❑ Depth To Water Table �.ed ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ San_4y Loam ❑ Clay Loam ❑ Clay ❑ Adobe,Hardpan C] Previous Application Made: (If yes,date--------------------) No New Construction: Yes U30INo ❑ FHA/VA: Yes ❑ No Er-- 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-J.4..t--_------.Material---'--.._-------------------------------------- No. of compartments------�7 _-_---Size---- A0-----------_Liquid depa h-_ -------------------Capacity..../_;4:��744 Disposa field: Distance from nearest well-_----------Distance from foundation.1 --p--......Distance to nearest I t line..`-�--_- Number of lines----------21-------------------Length of each line-----9_Q_----------- --Width of trench-_/_ . ---------------- Type of filter materiaGC- ,0_ � ----__Depth of filter material_-.�__ _'_�__._.--Tata! length-------/Z47----------------------- Seepage Pit: Distance to nearest well---- ----------Distance foundation_14o% : .Distance to neareEklot'line�__ �_�-__ �`-r q i, Number of pits--_.r�r------- --Lining material-_--_-_- _�4.-Size: Diameter---3 __-_-.......Depth_ ................. Q ` Cesspool: Distance from nearest well-----------------Distance from foundation--------------:-----Lining material------------------------------------- 0 Size: Diameter----•---------------------------------Depth-------•------------•-------------------------------Liquid Capacity--------_-----------•-•----gals. Privy: Distance from nearest well--------------------------------------------------Distance from nearest building----_---_----------_----___----_---_---. ❑ Distance to nearest lot line-------- ---------------------------- �.. ------------ Remodeling and/or repairing (describel---------------------------------------- ,. -------------•---------------------------••---•----------------------------------------------- I 9 ------•--•---•------ ----------------------- ----------------------------------------------- •---------------- ------------------ ------------ ------------- - --------- ••------•---•---••--------•-------------••--------- ---------------------••------------------------• -----------•--------••----- -........---......................------------------------------------------------------------------------------------------------------ ------ V 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 and regulations of the San 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 I APPLICATION ACCEPTED BY r------- --- --- ----- DATE .-" -/•• REVIEWEDBY -------------: ---------------------------------••--------------------- DATE BUILDING PERMIT ISSUED___--------- -------------------•-- ---------------–-------------------------------------- DATE...--------------------------- A Iterations and/or recommendations:..--..----------------------- ----- l _. - .. -------• - ----------------- ------------------- --- -------------------------------------------- ------------------------------ -- ----- FINAL INSPECTION BY:.----.:- -�� •--- ---------------` Date---------��..�_[._.------------------------- --- - ---`----------- _ 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 a-59 2M 5-62 ATLAS i