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FOR OFFICE USE: _________________________________________________________ M / " Permit No. ...1.-- APPLICATIOWFOR SANITATION PERMIT -- -------------------- ---------------- ------------- ----------------------------------------------------- (Complete in Duplicate) Date issued ---------------------------------------------------------- This Permit Expires 1 Year From 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 A D LOCATIONs -- Owner's Name -------------------------------------------- Phone--------------•-•--------- -----------------_---- - Address --------------------•------------------....---------•--•---•-----------. Contractor's Name----- IL-- .................. Phone..................-_--------.-_---------- - -•------ �i - Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living unit:: -_I..- Number of bedrooms ___t�t Number of baths _�L t size ._-r. ff --•• Water Supply: Public system ❑ Community system El Private, Depth To Water Table -------�tt. Character of soil to a depth 1.of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe, Hardpan ❑ Previous Application Made: i.(If yes,date--------------------) No 9 New Construction: Ye ] No ❑ FHA/VA: Yes ❑ Nok .I TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic „�,� Septic Tank: Distance-from nearest well_/& '-__Distan from foun lja ion---1-1.-----_.--Materia -- -^ - J----•-••.••..•----” J ��0 No. of compartments___-�-------------Size__� �?- --- ---Liquid depth___-- apaaty._._- -. -- �-J!_____...__.Distance to nearest lot line__� Disposal Field: Distance from nearest well-.1�_.__._�'Distance from foundation.____ - Number"of lines______________"-___ --- -- Length of each line_____- -Width of trench-------A..9................ tt Type of�:filter material., �2t ---Depth of filter material_____ _ _______Total length______..-1_6__®--.-.------••------ Seepage Pit: Distance to nearest well---------------------Distance from foundation--------------------Distance to nearest lot line----.------.--..- ❑ Number"of pits----------------------Lining material---------------------- Size: Diameter-------.. _-------_-.Depth-_..------.---------------------- � 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------------------------------------------ -4) ❑ Distance to nearest lot line------------_-------- ----------------------------------------------------_----------------------------------------------- -----------•------- Remodeling and/or repairing [describe):___________________"-___----------------•-•----.....------•------••--------- ---------------------------------------------------------•---------------•------ ---------------•--------------• -------------------------•------------ ---•---- .. I -------------•--------------------------------- ------------------------------------------------...-------- ------------------•-i;--------------- -----------•-•-------------------------------------------------- --- - '-----•• . -•------.. ---- ------- ----- ------ ---- ------- ----- hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State laws, and-rules and regulations of the San Joaquin Local Health District. II~ Signed � -----��►-.�.e?��•-------- -----------------------------------------------------------------------(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 ONLY APPLICATION ACCEPTED BY------------------------------ -----------•---------------- DATE--------------- / ------------------------------------ . -----------. DATE----- -------""------------ REVIEWED BY " --------- �. BUILDING PERMIT ISSUED--------------------------------------------- DATE Alterations and/or recommendations--_-----•------ -- -------------- --•--••----•-------•----...-----...........---•-•-------------------•--- -------• ------- --------------------------------- ` ••--------"-•----------------------••-------••-- A -----••---------•--•-----•---- ------- ----------•-•------------ --------------------- it -----------------------"-. FINAL INSPECTION BY:........ ... .. ------ ------ Date.- - SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 124 Sycamore Street 205 Wast 9th Street Stockton,California Lodi,California Manteca,California Tracy,California �•C •,L E5 9 REVISED B-59 2M 5-62'ATLAS