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OR OFFICE USE- ------ SE:-----" ------��-- APPLICATION FOR SANITATION PERMIT Permit No. " --------------------------- -------------------------- --{ ------------ -------------------------------------------- (Complete in Duplicate ---------------------------------- This This Permit Expires 1 Year From Date Issued Date Issued ----._.. 2 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. 173 -Z`E`D-r D JOB ADDRESS AND L CATION---Nd_a----- -----0 ---- -- ------------- .................. Owner's Name------4•'--- Is..- ,FsY------------------------------------------ -------------------------------- ------ Phone............... -------_---_---- - Address......L.3f-,'$------- ------------------------------------------------------------------------------------------ -------------- .....................••------------------------ ai� Contractor's Name----- .. •._. Phone................ .. S?1 4 --- �----rte Installation will serve: Residence [Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: ._.___ Number of bedrooms -3--- Number of baths -1.... Lot size ..G- - • 5 ...-----•----•--------------------- Water Supply: Public system [Community system ❑ Private ❑ Depth To Water Table i _Q_'ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe{Hardpan ❑ Previous Application Made: (If yes,date--------------------) No 1, New Construction: Yes [!r-No ❑ FHA/VA: Yes ❑ No TYPE OF INSTALLATION AND SPECIFICATIONS: ' (No septic tank or cesspool permitted if public sewer is available within 200 feet.) l Septic Tank: Distance from nearest well---------------- Distance from foundation_1A9_____.__.-._.Material_____1------- ____________........._____.___-_-. f [ No. of compartments__._!�_______________Size______�__X_�__ C--'_Liquid depth______ly_�____._____Capacity.-.--- �__..�4� Disposal eld: Distance from neares well'_- .-Distance.from foundat-on..fd_..........Distance to nearest lot line_�f ...__..... ! Number of lines____..______________LL Length of each line_ �_ ---------- of trench----------------------------------- Type _"Z_�.------_________-______ Type of filter materiaL�9_C!1___ ...Depth of filter materiaL____J_r-__--____.__Total length _-----------------___------- aP Seepage Pit: Distance to nearest ell_--------------------Distant from foundation__/O._f___--___.Distance to nearest lot Number of pits-- -------------Lining materiaLA�___.__.Size: Diameter-23.............Depth----OZ4_--/----------------- - , Cesspool: Distance from nearest well-----------------Distance from foundation-------------.------Lining material----.----------------------______ r.- ❑ 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 hereby certify that I have prepared this pit tion and that the work will be done in accordance with San Joaquin County ordinances, State laws, and rules and regulate s o the Sa Joaquin Local Health District. (Signed)---------------------------•----•-------------------------- ------- - ------------ ---------------------------------------------------------------------------(Owner and/or Contractor] BY: --------------.1 ------------ --- --------- ---------------------- (Title) (Plot plan, showing size of lot, location of system in rely ion to wells, buildings, etc., can be placed on reverse side. FOR DEP RTMENT USE ONLY APPLICATION ACCEPTED BY----- --- -- --- -� ,------------------------------- DATE---- . REVIEWED BY--------------------------------------------- DATE BUILDING PERMIT ISSUED--------------------- _------------ DATE---------------------------------------------------------- Alterations an or recommendtionsh______________________ _____. ------------------------ ---- Y________________ __ FINAL INSPECTICN BY:..---- - Date �-_-- 4 6 Z 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 21A 5-62 ATLAS