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FOR. OFFICE S . 1 - ...� APPLICATION FOR SANITATION PERMIT Permit No. . .... ... ------ ------------------ (Complete in Duplicate) --------------- 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. 54 JOB ADDRESS AND LOCATION......... ......��,� -------- ---... -9-`�-- --- ---------------------•-- =.... -------- Owner's Name.............. --- ------- , � f" *------------------ -------- ......... = Phone f Address......................... /J/✓" --��...._--� - -------- •- �--�------- ------------------------------------------•---- Contractor's Name--------------•--=---�.1 ` 5....--------- -----------------:... <......................................------------- Phone.•- :-••-- Installation will serve: Residence p!p Apartment House [-ICommercial E] Trailer Court [3Motel [I Other Number of living units: __umber of bedrooms ..'7Number of baths _..1_ Lot size ------- 0" . S f,. Water.Supply: Public system .f�'Community system ❑ Private ❑ Depth to Water Table __ `1'ft. haracter.of soil to a depth of 3 feet:. Sand _Gravel .. Sand Loam -Clay Loam [D-Clay E]—Adobe❑ Hardpans ❑ C p ❑ ❑ Y I�' Y Previous Application.Made: [If yes,date-----------------._) No " New Cbnstruction: Yes Na L] PHA/VA: Yes ❑ No'{ '*rTYPE OF INSTALLATION.AND.SPECIFICATIONS: ! (No septic tank or cesspool permi ed,if public sewer is'arailable within 200 feet.) Septic Tank: Distance from nearest well------- ::.�"Dis#ance from foundation....................Material---------------.------e................�._.... ❑ No. of compartmen+s----- -------- ------ Size------------------ • --------Liquid depth-------------------•------Capacity --------. ---•E_.... . I a r �� 1i } Dispo4l Field:' i Distance from nearest well-,_--f-----...._.____istance from'foundafibn]___ r'....'Distance to nearest.lot line ... ... Number of lines.__- .......... Length of each line..-------J f ,f._...Width of french.------------ .............i. l Type of filter material...__ ._Depth of filter material--------- -- -----Total length....-.....1 ................#-_•-- Seepage Pit: Distance to nearest-well-_-7�i Distance fr fo dation_.._ .___.Distance to egrest lot,.line....�:.._.... ` 'r vL If 1 -- -.. Number of pits......'......-.----Lining material---- .Size: Diameter------------------- th_....... -.--_-_-•- Cesspool: Distance from nearest well-----------------Distance from foundation----.----------------Lining material--------_,._-------•-------__----__. Q ❑ Size: Diameter--------t----------------------------Depfh.-.•---------------- �__Liquid Capacity------.r.................gals. ( _ ----Distance from nearest building--------------------------------- ........ Privy: � . Distance from nearest well----------------------- -----•----------- 9-----•-••-•-•-•-----•-•-- ❑ � _ _ -----------............................................... ... �� t5 � Distance to nearest .lot line.............._._..._. t i 5. jj Remodeling and/or repairing (describe)-------------------------------------------------------------------------------------••---------------•---------------------- --------••----•---• € i t I ---------------------------- -----------------------•-•••--•--------- } f •------ ----------------------- I ----------------------I hereby certify that I have prepared this applicati n and that the work will be done in-accordance with San•Joaquin County ordinances; State laws, and rules and reg I iorf of t - n Jo uin Local Health District. j (Signe ... t--••-.--•- ------------------------------------------ - --•--------------------------------•-•-----------'----(Owner and/or Contractorl 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 ONLY = - , APPLICATION ACCEPTED BY ---- ---------- ,. --- REVIEWEDBY-------------------------------------- : --------------------------------------------------------------•---------•---•--• DATE---------------------------------------------.............. BUILDING PERMIT ISSUED '----------------------•-•-•-------------------------------------------- DATE.. - I Alterations and/or recommendations:--------- ------- =- ----- ------------------•----------•-------------•------..............................-....................................... ---------c -- - �......��...... ._..� , = --- v ....................•••••.. r J FINAL INSPECTION BY:..I_c.----- ---G�- --- Date...._4 `J d -----`--•- -------------------------- 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 t ES 9 REVISED B-59 2M 8-61 ATLAS ��. -