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FOR OFFICE USE: 1 -------------------------------------------------- --------------------------------------------------------- APPLICATION FOR SANITATION PERMIT Permit No. ......... ---------------------------------------------- ------- (Complete in Duplicate) --------------------- This Permit Expires 1 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. 549. JOB ADDRESS AND LOCATION---�'-_-,_�.?------- -•----.4.G �, .`� ° ._...... _Lf_F_ Owner's Na(ame ' s -.! �------4 --1•-----`-'�'/-k-•----l--ir-----�---------'------f -C- - ------------1----------------------------•---•------•-.-------------------------•----------P--h--o--n--e....-.:.S----••7--•7---.=._..4._Z/:•---3 Address........ AA.. .....�.b--•--A--i•--- Contractor's ...___ =7._._... -- !1i T o/lr ............... Phone.-� :3: Installation will serve: Residence WJ Apartment House E] Commercial E] Trailer Court ❑ Motel ❑ Other Number of living units: _1... Number of bedrooms __ ._. Number of baths __4... Lot size ....Xa...X_......Z: ...................... Water Supply: Community system ❑ Private„j 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 Z FHA/VA: Yes ❑ No,® TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tank: Distance from nearest wells-----------Distance from foundation....................Material................................................. ❑ No. of compartments--------------------------Size-------------_---------------Liquid depth..........................Capacity....................... Disposal Field: Distance from nearest well__- Distance from foundation.....��?_........Distance to nearest lot line... ....... Number of lines------_---_- $( __________________Leergth of each line----------- - �-'__.a_-'__-_-Total length.....S.d............................ Seepage Pit: Distance to nearest well----------------------Distance from foundation....................Distance to nearest lot line................. ❑ Number of pits----------------------Lining material--._______.-_---_--_-__Size: Diameter_....................,Depth................................. 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--------- --------- --------------------------------------------•---- Remodeling and/or repairing (describe):------W-a"':T'b2T------..._------ I—,-Vf Arr.....•---- 5 P-P rs c ------ LY..&.......... 0*vlvc--------------a__ C---------7ar,A_eT...........al ky-----------•-------------------------------------------•------------------------------------------------- d ----------------------------------------------------------•-----------------------------------------------------------------------------------------------------------------------------•------------------------------------ ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ 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)------------- "__c____.. '` 17_vt!rI/___-- -.-•-sd (Owner end/or Contractor) • �- (Plot plan, showing size of�ot, cation of system in relation t0 wells, buildings, etc., can be placed on reverse side). FOR DEWfMENT USE ONLY APPLICATION ACCEPTED BY------ -------------------•-•••--••--•--•--••-• DATE REVIEWEDBY-------------------------------------------------------------------------------- -------------------------------------------- DATE--------------------•----------------------------••- BUILDINGPERMIT ISSUED--------....................................................._...................................... DATE............................................................. Alterationsand/or recommendations:---------------------------------------------------------------------------------------------------------------------------------------------------........... -•----------------------------------------------------------------------------------------------------------------------------------------------•---•-------•----....------------------------------------------•-•---•---••- ------------------ FINAL INSP BY:. ----------- Date------------f----�s�----^-- �~, ;---------- 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 8.59 2M 5-62 ATLAS