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FOR OFF! E USE: yi----._-.--. --------- -- APPLICATION F6R SANITATION PERMIT Permit No. ------------------------------------------------------"- (Complete in Duplicate) ' ------------.--- This Permit Expires 1 Year From Date Issued Date Issued ............ ..._h Application is hereby made to the San Joaquin Local Heal District for a permit to construct and install the work herein described. This application is made in compliance with County Ordi ce tlo. 549. JOB ADDRESS ANS, LOCATION----A-X31- .- ., Owner's Name----- Phone_:=` ---------------- ddress...............................5! .. tib------=------- - ---------------------.-----------•------------•-- Contractor's Name... Phon . Z ,7 Installation will serve: Residence ❑ Apartment House ❑ Commercial [❑ TraUjisize rt ❑ Motel ❑ Other . ` Number of living units: -------- Number of bedrooms -------- Number of baths. _ .__.__ __��1._.. .�_Q.Q.�................... Water Supply: Public system Community system El Private L] Depth To Water Table 6.0- ft. Character of soil to a depth o 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe)9 Hardpan ❑ Previous Application Made: (if yes,date--------------------) No ❑ New Construction: Yes ❑ No jW FHA/VA: Yes ❑ No ❑ TYPE OF/1NSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) S tic ank:- Distance from nearest well-----------------Distance from foundation-----............--Material__----------__-_._.--__--------.---------_--_-.-. off` No. of compartments--------------------------Size--------------------------------Liquid depth--------------------------Capacity------------------•-•-- is al Fi Id: Distance from nearest well.....-- Distance from foundation--------------------Distance to nearest lot line.................. I� Number of lines-----------------------------------Length of each line------------------------------Width of trench................................... Da Type of filter material--------------------- ---Depth of filter material.........--------------Total length----_-_---.-.------.---------------------- Seeps a Pit: Distance to nearest we l Distance' r �f undation �� ..Disn Distance to nearest lot line_.�110/. ew Number of pits______ ______________Lining material- Q---�--._Size: Diameter____-.__.._._._.._..Depth-------- Z ------____--- 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-----------------------------------------------------------------------------------•-------------------------------------------------------- Remodelingand/or repairing (describe)-------------------------------------------- ----------------------------------------------------•-••-----•-.•---•-•-•--•.....---..............-•--------• ---------------------------------------------------------........----------------...-•-------••-------------------------------------••--------•--------••---------------------------------•---------------------------------- --------------- ---------------------------•---•---------•-----------------------•--------------•---------------•---------------------------•-----------•-- ---------------------I__----------------- ----- I here ce ify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinance , to laws, an rules a regulations of the San Joaquin Local Health District. (Signed- �' `! - r and/or Contractor] -- ---- - - ------------------------ -- --- ----- r and/or ---- .-------------------(Title------------- --------- (Plot plan, showing size of lot, location of system in relation to wel buildings, etc., can be placed on reverse side). FOR DEP RTMENT USE ONLY APPLICATION ACCEPTED BY.- DATE_-___- ___` � ._. ___� ----------- -------------- ------- REVIEWEDBY--------------------------------- •----• ------ DATE--------------------------•------------------------------- BUILDING PERMIT ISSUED----------------------------------------------------------------------------------------------------- DATE------------------------ ------------------- --------------- Alterat'ons and/or recommend-tions:_ -_ ------------------ s. __ __ ----------------------- . -------------- -----------&...3------ - ------ --------------- ----------------- -. �_... ------------ _ rte, •--• r ------ ----------------------------------------- -- --- c_�- - Y+�- , Gtr.-� . -�—�. - �_ .. Q - --------------- - FINAL INSPEECTlON BY:.................................-- ------------ - -- - • Date------f� / 7;� - ------------------•--••---------_.,.------------------------------------ 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