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FOR OFFE JGS'I �w � 6 --------------------------------------------------------- APPLICATION FOR SANITATION PERMIT Permit No. ........................ ----------- -•-------------- --------------------------- (Complete in Duplicate) . Date issued ----- ------- ----------------- -__ This Permit Expires 1 Year From Date Issued �ft~( p (-77— 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. r 3 -- :f'- ` JOB ADDRESS AND LOCATION---------y ----- 7 , �--- _-------------- ------------------ ------------------- Owner's Name-------------- � �r- Phone- -�Z:p_�?---X l .a- ------------------------•----•-----------•---------•--...------- Contractor's Name...........-------- ----- -•-•----------------•-------------- ------ Phone..--- ••-----•---------------- Installation will serve: Residence E3---X-partment House ❑ Commercial Trailer Court Motel Other Number of living units: ._.!___ Number of bedrooms _7___ Number of baths __/.-. Lot size .-. - -- .. �- Water Supply: Public system ❑ Community system ❑ Private [Z Depth To Water Table 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 0--New Construction: Yes [ No ❑ FHA/VA: Yes ❑ No TYPE' OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic T k: Distance from nearest well____.1---__Distance from foundation---./_a____._.Material.._____ 1 �_Li uid de th____--__._. - Capacityo No. of compartments---------- ,Z' G P. moi'--- ----•• ... Dispogal Field: Distance from nearest well-._._ __._Distance from foundation__..... -__...Distance to nearest lot line___. ._.. Number of lines-------------------- Length of each line------------C-__a-.-------Width of trench----------- -------.-- Type of filter material. - . .Depth of--filte'r material/ ��-"-_.-Total length------ ..__/___?— -_--___----_ ' Seepage Pit: Distance fo nearest well__----_---------------Distance from foundation -..-:___---___.Distance to nearest lot line------------� [� Number,,of pits----------------------Lining material__....-----------------Size: Diameter---- from nearest well_________________Distance from foundation---.---------------.Lining material____.________._-____----_ .._._ Cesspool zee Diameter--------------------------------------Depth----------------------- ------Liquid Capacity, -------- gals. Privy: Distance from nearest well-------------------------------------------------Distance from nearest building------------.---------------- ----- I ❑ Distance to nearest lot line----------------------- ----------------------------------------- ---------------------------- Remodeling and/or repairing (describe)---------- --------------------------------------------------------------r"---•------------••---- :r :-------------I.............................. --------------------------- ----------------------------------- ---------- \ "V --------------•----•--------------------------------------------------------------------------------------------••--------------------- ----------•-------------------'--__....--------------------------------- --- -- -------------------- - I hereby certify that I have prepared this application and that the work will be done in accrdance with San Joaquin County ordinances, State laws, and rules and regulations of the San Joaquin Local Health District. y (Signed)_ (Owner and/or.Contra 1 By:•---- 0 'ti {Title) ,- (Plot plan, showing size of lot, location of system in relation'to wells, buildings, etc., can be placed on reverse side). y,- OR ARTMENT USE ONLY --,- mow, ... APPLICATION ACCEPTED BY---------------- - - ------------------------- -- DATE- -------•- ---- ------- ------ ----------- - REVIEWED BY------••-------------- - i ---------- ------------------------------ ;=�_ '.DATE ---------------- •------------------------ BUILDING PERMIT ISSUED------•--------------------- -- ---•-- DATE..------------------------------------------------------ Alterations and/or recommendations:-------------------- - ---------------•--"---------- " --.-----„--•-•---------•-------------------------------------------- --•--"•---------------------•------------------•-- --•----•--•-----"--"------•------•-------------------------------------------- - FINAL INSPECTION BY:--t--- i ------ Date------- ---------- ---C_ ...6.. ..----------------------- ....... ... ...• - -��'-`�`r--•---- - SAN JOAQUIN LOCAL HEALTH DISTRICT. 130 South American street 300 Wert Oak 5rreet 124 Sycamore Street 205 West 91h Street Stockton,California Lodi,Cc fertile Manteca;California. Tracy,California E5 9 REVISED 8-59 21A 5-62 ATLAS { R �