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FOR OFFI U : ,1�,' APPLICATION FOR SANITATION PERMIT Permit No. .. ..a/�/_ _ ----------------------------------------- --------------- (Complete in Duplicate) �7/ --- --- This Permit Expires 1 Year From Date Issued Date Issued _3111, __,l ��. 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 complianc7 withn Ordinance No. 549. JOB ADDRESS AND CATION - d-/- Owner's Name r ........ -------_--•-------_-------------------------------------- ----------------- --------- Phone.................................... � e Address---•.-.4- �7 ---------------------------------•-----------• Contractor's Name,,, --±----- ------ -3----••-------------------------------- � --------------- Phone------------------------------•--- Installation will serve: Residence Apartment House [ICommercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: / Number of bedrooms ._ Number of baths .. ... Lot size ,11*__X___I _7.................... Water Supply: Publics stem y [r—Community system ❑ ~Private ❑ Depth TO Water Table ........ ft. I Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe B—Hardpan ❑ Q Previous Application Made: (If yes,date--------------------) No- New Construction: Yes P!r""N�o ❑ FHA/VA: Yes ❑ No — N 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 from foundationb/ -'r'............ ..r...........Material____.___ _ ------_---. No. of compartments-------,-------------Size___ _ = _ -----Liquid depth---. ........---------Capacity___ !". { ..... pisField: Distance from nearest well...---.___._Distance from foundation__/D_�___......Distance to nearest lot line__ ^�..._. Number of lines..........___ __ __ Length of each line_____?A_`..............Width'of trench___ZA..`-`.........____.....__ Type of filter material_:_/_LSC_. ___.-__Depth of filter material._l _�`----------Total length._.__. �`_.�__________________________ -- j31 -- See a Pit: Distance to well__ _ ___ _g___Distant;from foundation_��....____-.._. stance to nearest lot line_.......___._ p � � << r Number of its------/--------------Linin material?a-C,--_[-----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--------- --•---------------------- ---------------------- Remodeling ------------•-------Remodeling and/or repairing Idescribel:----- ------------------------ ......................... ------------•---•---------------•------------------------•----------•------.-------------------------------- I hereby certify that I have prepared h' appl' at and that the work will be done in accordance with San Joaquin County ordinances, State laws, and rules and reg I ions the San aquin Local Health District. (Signed)------------------------------------------ --------- ------- ----- - ------ --------------------4 ' ----------------------------------------(Owner and/or Contractor) By: -........ ---- --- ------ ------- = = (Title)- - -----------Title (Plot plan, showing size of lot, location of s stem in rela ion to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY------ - " 2-c,,a------------------------•---••---------------------__---- DATE------. REVIEWEDBY------------------------------------------------------------------------------------------------- ------------•--------------- DATE-------------------.------------•-•-----------._.._._........ -BUILDING PERMIT ISSUED..............................................................---------------------------------------- DATE------------------------------------------------------------- Altdrafionsend/or recommendations:�. ------------------------------ --------•-----•----•-----------------------------------......---....-----....---------------------------------..---- --•---......�� 6 --�-- Z..---------------•-5l e-----------•------------------ ----•-- --- ----- - _.�=�7-"�, l�lr=: -,_. -- - -- -- -I------ �' r - . X!- - •--------- ---- t/ FINAL INSPECTION BY:.------C " ---------------------------- Date-----------7J17-a. . 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 E5 9 REVISED B-59 2M 5-62 ATLAS