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FOR OFFICE USE. ----------------------------------------------- --------- --------- "--.�4- -------------- -------------- APPLICATION FOR SANITATION PERMIT Permit No. :. - rt- ------------------------------------- (Complete in Duplicate) ----------- --- This Permit Expires 1 Year From Date Issued Date Issued . =_,� -- 3 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. eL-�6 --------------------------------------- -------------------------------- -------------- JOB ADDRESS AND LOCATION Owner's Name-_ Phone... - Al Address A2.6713 •� � ---------------------------------------------- --...------------------•-------------------------------------------•---••- I Contractor's Name-----•. ----0 --------------------------------------- ----------...----------•--......................------------- Phone................................... Installation will serve: Residence [Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: ...... Number of bedrooms -1., Number of baths J... Lot size .............. Water Supply: Public system Welec-ommunity system ❑ . Private ❑ Depth To Water Table -. 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 EK New Construction: Yes ❑ No ❑ FHA/VA: Yes ❑ No ❑ ' TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) S tic T k: Distance from nearest well...._.._......_Distance from foundation--------------------Material----------....................... -.-. No. of compartments`= ti--=;----- ------- ` . S;Ze, -----------------------Liquid depth-------------------------.Capacity----------------------- Disposel ield: Distance from nearest well...............:.Distance from foundation....................Distance to nearest lot line----------------- Number of lines----------------------------------Length of each line.-=----------------------..._.Width of trench--------------------------•---.... Type of filter material-------- ---------------Depth of%filter material-----------------------Total length.........---------..--.--------..--.__---- Seepage Pit: Distance to nearest ❑ well........._----.--_,---Dist'ance,yfrom foundation....................Distance to nearest lot line................. Number of pits----------------------Lining -------Size: Diameter-----i--------•---- p Depth------------------------.-------- (� Cesspool: Distance from nearest well-_---'. ---`:.Distance from foundation--------------------Lining material......-----------.-..-.----------...- ❑ Size:diameter.: "--'---- "---------".`:c._Depth----------------------------------------------------Liquid Capacity_ gals. i P tY Priv Disfane from nearest well. _...._..-------._-. ...Distance from nearest building ..--..--..- ❑ Distance to nearest lot line............................_-------...._....._ �---'~ Remodeling and/or r�pairing (,describe)- ------------------- ----------Z------ --------------- describe): -- -- •-------•••------------------------ -------- ------- �f�t ' ---------- -r`--"`-�"'"•-- --- 1�� `=--- -- --' - - - -� - - All Ge� -------------- I hereby certy,� hat I have prepared this application an t the work will be a in accordance with San Joaquin County ordinancejSte[Ayk and rulesand?regulations of the San Joaquin Local Health District. (Signed- r --------------- -------- ------4--------------------------------------------------------------------------(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). - FOR-DEPARTMENT USE ONLYf r APPLICATION ACCEPTED BY----------G...�y- )-------------------------------------_----_------------- DATE--------- -�� ------------------ REVIEWEDBY--- ----•-------- ------------------------ -_------------------------------------------------------------------------------- DATE---------------------------------------------•--•----------- BUILDING PERMIT ISSUED-------------_------------------------------------------------------------------------ --- ------ DATE------------------------------------------------------------- Alterations and/or recommendations:---------------------------------- ------------=- --------------------------------------------------•----....----••--------------------------------------------------------------------------------------------------------•--........----------•-----------------.------------- ---...---...------------------------------------•--------------------------------•----------------•---•-----------.......-----------....----------•----._...__.....__.....--------••-----•---------------•---•----•_."..----- i ------------------------------------------------- ----------------------------------------------- -------------------------------------------------------------------------------------------------------------- FINAL INSPECTION BY--- ---- -------- f%-Gfc�-----------------"=- . . Date------ =1-�,3 ------ — L ~{' SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,California ?t Manteca,California Tracy,California ES_9 REVISED 8-59 2M 5-62 ATLAS