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FOR OFFICE USE: ` APPLICATION FOR SANITATION PERMIT Permit No. .. .......�- -•� ------------------ '� --- -__-- -?�,------1 Issued (Complete in Duplicate) ---------- --•_-.--•- .{°J --------_........______-------_-----------______ This Permit Expires 1 Year From 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,0i Ordinance No. 549. JOB ADDRESS AND LOCATION._'_�_-'�.r4`>�-�_.�->> ---L�1-----�G��.,�c�.CJ.__�t--��,��-,��---•-' Owner's Name..-- ---•• Phone Address-••--•--- .. .. ..-_ .............. •- • ••-----•-••-•---•--•-•-•-••-•---••••-•-•-••••-•----•-•-•-•••-••---------------•••-•--••-•----__...........•-•-•--•-•••--...... Contractor's Name..... � -•• ----• -------•---------------................... Phone................................... Installation will serve: Residence ®'-Apartment House ❑ Commercial ❑ Trailer Court [I Motel ❑ Other ❑ Number of living units: Z--- Number of bedrooms .cA—. Number of baths __/_._ Lot size _1 `./'G...................................:.. Water Supply: Public system ❑ Community system ❑ Private [Depth to Water Table tsi Character of soil to a depth of 3 feet: Sand F] Gravel E] Sandy Loam[I Clay Loam ❑ Clay [3 Adobe�'Hardpan ❑ Previous Application Made: (If yes,date--------------------) No New Construction: Yes Ua--'-No ❑ FHA/VA: Yes [j'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 well Distance/frro! foundation_fj�.._ __.___.Mater`L _!P! _ . .................. No. of compartments.....�--------------Size_AX;v _,t'_1/'4P __Liquid depth....... ............Capacity./d ..... Disposal Field: Distance from nearest well__elli?------ Distance from foundation__ p____......Distance to nearest lost liner-.._...... Number of lines__________ ___ ____________ Length of each line..... _.. ..............Width of trench—e'. Type of filter material.l P epth of filter material____.1O"i—.__..Total length,.______,�_��_________________________ _� Seepage Pit: Distance to nearest well----f. /_Distance frim foundation...: ........ r�ce to nearest 19t line_.✓` ..___.. Number of pits......./...........Lining material____,_�_O _._.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------------------------------------------ 0 Distance to nearest lot line------------------------------------------------------------- ... Remodeling and/or repairing (describe):. ... -----------------------------------------------------------••-------------------------•--------•------------------------------------------------------------••----•-------.._.._.__....__.....---•---•--••------_-•-•- 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)--• `;%% ..�? � ------------------- ---- ----------------------------------------- - ( Contractor) , Y••--•-•...._•-•-•--••--•-•--•---•---•. -- (Plot plan, showing size of lot, location of sys in relation to wells, buildings, etc., can be placed on reverse side). FOR EPARTMENT USE ONLY APPLICATION ACCEPTED BY---- ------ - - :--= ------•---•-----••--•---•-•-•-•-------•-••- DATE........f� •-•-�--•-- -----a.I................ REVIEWEDBY---------------------------------------------- 1------------•-------�-7•-----•-------•--•------••-•-•---•••-__--••_. DATE............................................................ BUILDING PERMIT ISSUED `/ _ DATE Alterat'ons and/or re ommendations:.. __. .............................................„_ c1.............. f (, .'j�, ------------------------------------------------------------------------------------------ - --------- ---------...................................................... FINAL INSPECTION BY----------- ------ -- •--•---------------- Date---------- �_Ih--l........................................ SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 124 Sycamore Street 205 West 9th Streit Stockton,California Lodi,California Mahti�a,.!G`dllforpla Tracy,California ES 9 REVISED 8.59 IM 5-61 ATLAS '� -