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FOROFFICE USE: --------------------------_______________________________ APPLICATION FOR SANITATION PERMIT Permit No. ...._..._._... _.- ---•-------------------•----- -------------------------- (Complete in Duplicate) 1/ �r!Z ------------------------ --- 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-----LI-0--l. 9.� 5 - ---------- Owner's --------Owner's Name-------- •,----.--• �_XAJ-.2-A------------------------------------------------------------------------------------- Phone---................................. Address.......�--- -----:.. - V1_+--------- Contractor's -Name= .,-5 4 -------------------------------------------------------------------------------- Phone..4.6...�.-. 1�.c Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other E❑ Number of living units: __ ----- Number of bedrooms _7�n_ Number of baths V�Z._Lot size ...�Ll_-__-.? _]_ ©,`.:...................... Water Supply: Public system K Community system ❑ Private ❑ Depth to Water Table-a'`�_�G ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clayy❑ Adobe IL Hardpan ❑ Previous Application Made: -(If yes,date-------------------- No -New Construction:"Yes q Na ❑ FHA/VA: Yes ❑ No s ��r TYPE OF INSTALLATION AND SPECIFICATIONS: = - (No septic fank•*Ir cesspool permitted if public sewer is available within 200 feet.) r � 1 Septic Tank: s Distance from nearest weli.l'�O,IAA.-_Distance from foundation---1_(�------------Materiel ��1.>~�............... No. of compartments__-_-_Z-_____________Size. ..'i��___`�._.�_,___Liquid depth-_.�.:�- ___________Capacity-_-`3. .. k Disposal Field: Dista ce.from n crest well._At,.KS,_,Distance from foundation----1_0--___.___.Distance to nearest lot line . ._.�`�...�...... ♦- tis. 1 ,ry Lk N I I of�liries..:.____I------•-------------------Length of each.line-----. 1-----------------.Width of trench---...';-A--------------------- i I Type..-,of filter mate rial�Nft-P*_c_rmclDepth of filter material....._1__i�. ..........Total length----------E-A k----------------------- Seepage _____________________Seepage Pit: i Distbrice to nearest well----�a_ RDistance from foundation.._.__L. �__--._.Distance to nearest lot line____s__! __--, Number of pits----------(-----------Lining material---- 11- c • ----Size: Diameter_:- ----------..Depth----z .................. Cesspool: Dista . Distance from nearest dell_________________Distance from foundation____________-______.Lining materiel_...._____.____. ......___.__ ❑ $Fzd: Diameter--------------------------------------Depth--------------------------...-----------------------Liquid Capacity---•------- -?:.....------.gals. Privy: Distancs from,nearest well j--------------------------------------------Distance from nearest building-___-..___________-=.................... Dstance to nearest lot line---`-------------------------------------------- -••-- ----------------•-••---•------------•--••--------•------------f-----•-------------- I ;A c7, T Remodeling and/or repairing (describe):_"__________--__._._._ ---------------------------------•------•---•------------------- r -••---' rt_ _______________________________________________________________________________________________________________________ _______________________________•___-___________._....___....----_---___--___-____________-.---_. I hereby certify that I have prepared this application and thaf the work will be,done in accordance with San Joaquin County ordinances, State laws, nde. 6 a -regulations of the-San-Joaquin Local Health District. t ---------p ' f 'd (Signed)..--- ----- --••---•--------------------------------------------------(Owner and/or Contractor) 13y:. -------------------------------------------------------•-•.........---------------------------(rile)----------------------------- (Plot plan, showing size of lot, location�of;sysfem in relation to wells, buildings, efc.,can be placed on reverse side). FOR DEPARTMENT USE ONLY G APPLICATION ACCEPTED BY C -5-------------- ' ` • --------------------- DATE---1-]--~--- -. .. REVIEWEDBY----------------------------------------------------------------------------------------•------------------------------------ DATE--- •BUILDING PERMIT ISSUED--------------------------------------------------------------------------------- ------------------- DATE---------•-•--- Alt er tions and o recommendations:_- - Z.O_ fi��_____-___. p' _ _� ' �, - t r --------------------------------- ---------------------------- ----------------------------- ------ ----------------------------- ----------•------------- -•-------------- ------- --------------------------------------------- ----- --------------------------- -- --- - ------------------------------ FINAL INSPECTION BY:. 1 t Date ....--•-------------------•---------------•- -- > SAN JOAQUIN-LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Srreet 124 Sycamore Street 20S West 9Th Street Stockton,California Lodi,California Manteca,California Tracy,California EB 9 REVISED 8-59 ZM 8.61 ATLAS