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FOR OFFICE USE: - --------------- ------------------- ------------------- APPLICATION FOR SANITATION PERMIT Permit No. ....................... (Complete in Duplicate)' G Date Issued -----------------------.......................__.__ 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 County Ordinance No. 549. JOB ADDRESS AND LOCATION.______: : ___. .b. �-- .- -= � ' --` a"1-"p f T� Phone------------------------------------ Owner's Name------------- Address---------••-------------••--- ----------- ...... n LLQ` —-D _!.................................................. Contractor's Name----••----------------------- ` -------------------------------------------- -------•----•------------------------- Phone----------------------------------- Installation will serve: Residence ❑ Apartment House ❑ Commercial ❑ Trailer t [2/Motel ❑ Other ❑ Number of living units: .r __ Number of bedrooms Number of baths _1.... Lot size ------------ ------- Water Supply: Public system ❑ Community system ❑ Private [/Depth To Water Table 3.57-ft. Character of soil to a depth of 3 feet: Sand B'Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe❑ Hardpan ❑ Previous Application Made: (If yes,date__________________ I No [E' New Construction: Yes [-"lo ❑ FHA/VA: Yes E-- No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank rmcesspool permiffed.if public sewer is available within 200 feet:) - - — — p , , 1 l .....................�-o-o ------ a ,.__Lt uld de th Ca act .... � Se tic A: Dis ance from nearest well__�O__-___Distanc from foundation__................Mater L__...___ _ . NoJ of compartments____�._________.._.l.Size__ .. q p A ty �� Disposal Field: Distance from nearest well____ _..._Distance from foundation__-.. ----------- to nearest lot line______ NUTnber of lines__--_......____________________ _ Length of each line__-____ Width of trench....... `{ ' Tye of filter mate rial.�e��1 ft Depth of filter material_____ _ _________Total length............p5-_`--.__-•_._______._ Seepage Pit: Distance to nearest well----------------------Distance from foundation___:__.------------:Distance to nearest lot line....._._-_______- ❑ Nu ber of pits----------------------Lining material-j-----------------`--Size: Diameter.=------------------__Depth-._-----------_.--.--- ------ p Cessool: DiP q p --- -- s ,.__ ❑ Siz``ante from nearest well ___.____Distance from foundation---------------------Lining material__.__._______-_____. -f: Diameter----------------- -- • --- ---- _.---- De th--••----=-------- -•---- ---- ------------------ Liquid Capacity Privy: Dis ance from nearest well------------_________________-____.------------- Distance from nearest building -'-------------------------� ❑ Distance to nearest lot line-_----- ----------—---------------•----------------_------ and/or ---- -------------------•-- - Remodelin9. repairin9 (describe): . ----- -- -----. '. - - ---•----• ----- -------•-•--------•------- Pr.. • ------ •- --- �llnct � C --------------------------- - ?' • hereby certify that I have prepared this application and that the w will be done in accordan w!f SanlJoaquin oun ordinances, State laws, and rules an regul tions of t e an Joaquin �ocal 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). I. FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY --G DATE--------------------- -------------------------- REVIEWEDBY----------- ---------_ ------------- ------------------•-- ----------- ------------------ -----------• DATE------------------------- -------------------------------- BUILDINGPERMIT ISSUED-------------------------------------------------------------------------------- --------- DATE----------------•-----------------------•------------------•- Alterations and/or recommendations:.._-__.._______..____.___._ � _ r Z _ -- ` - - ----------------- - - ---- --- ---- ------- ---------------•----• ----------- — (� f FINAL INSPECTION BY:............... Date_....---------- a SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Stroot 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,California Manteca,California Tracy,California ES 9 REVISED 8-59 2M 5-62 ATLAS