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--FOR OFFICE USE: ------ ----------- -------- -. 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. 549. JOB ADDRESS ANZx.ATI N__.... 1-------- r� ��,5�------------------ ---•---------------------------------------- Owner's Name .. --• ---- -------- --------------------------------------------- Phone.................................... Address = .................................----•-•- - ---- --------------- Contractor's Name.. ..d - -- -- .12- -- ----- ---------------•••------------------------------------------••------•-•- ---•-------------- Phone Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: _1____ Number of bedrooms _ Aumber of baths _.�... Lot size --__.Lf�,,r __________________________--2---Number Water Supply: Public system [Community system ❑ Private ❑ Depth To Water Table ft. Character of soil to a depth of 3 feet:- Sand ❑ Gravel ❑ Sandy m ❑ Clay Loam ❑ Clay ❑ Adobeardpan ❑ Previous Application Made: (If yes,date---------- No New Construction: Yes ❑ No {A/VA: Yes ❑ No 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 foundation-------------------.Material------------------------------------------ ....__. �r No. of compartments--------------------------size..------------------------------Liquid depth----......................Capacity-------•--------------- Disposal Field: / Distance from f nearest well-----------------Distance from foundation-------_------------Distance to nearest lot line................. Number oflines --------------- -Length of each line------------------------------Width of trench-----._..---.------------._-_ --- TYPefilmateri -•------------------ length 9 Depth of filter material_______________________Total length---_•_____________---------_____________-- rV Seepage Distance to nearest well_____ ______Distance from foundation__. ...............Q7istance to nearest lot line..._.____ Number of pits._____-_�.-___.______Lining materiaL.�('' _ _ '_.Size: Diameter-___ __' _`/____.-Depth---c�..�__/_____ _______ �� C I es ool: Disfance from nearest well_________________Distance from�fou�hdation�� 'Lining materiSl_-_.-- ❑ vy ., Size: Diameter------'----- ----- r3'�-�:_°p------------._._Depth________.-_ a -----Liquid Capacity gals. Privy: Dis;;ncafrom nearest well------------- ` Distance from nearest building------„------------_-------------- ❑ 4 .Distance to nearest lot line----------------------------- ^r" k ---------------- -- - •-------••------- Remodeling and/or repairing:(describe): -- •---••---------------------------- -- .- t T f --- -- ------•------------------ •-----------•---•---------•-------------- --------------------------------------------:'---------------------------------------•-----•-•-----------------------__-=------:.._._.—____,...._.._.'-`_..-----•------------------------ I Hereby certif that I hav ared Aista�pplication and that the work will be done in accordance with San Joaquin County ordinances, State w red r, r'egulatio'ns of the San Joaquin Local Health District. (signed}. -- -- --- ----------------------------• --- --•-------•---------------------/�' (Owner and/or ntraatorl By:. - (Title)--..-G-------------------------•-_.._.-.. ---------- ------ (Plot plan, showing si lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY-- -� ------------------------------------------ DATE. 7� REVIEWED BY----------_----_------------- I- -- ------------------------------------------------------------------•-•----•----------- DATE---------------•--------•-` BUILDING PERMIT ISSUED-------------'---.._.._._..-----------------------------------------••-- ••-------•--------------- DATE.------•---- Alterations and/or recommendations:-----=------------------ -------- ------------------------------------------------------------.---------------- ------------------------------------------------------------------------------_-..------------------------------------------------------- ---•--------------------------------------------------...... --------------------------•---••-•-----------------------.....------------ ----------------------- ------------------------------------------------------------------------- --------------- ----------------- --------- ----- ---- ------- ------------------------------------------ -•--•--•---- ------------------------- --------------•-------------------- FINAL INSPECTION BY:.. �` ---- -- Date------------------ -------------- SAN -------------SAN JOApUIN LOCAL'HEALTH DISTRICT .130'South American Street .300 West Oak Street 124 Sycamore Street 405 wast 9th Street Stockton,California + Lodi,California Manteca,California Tracy,California E5 9 REVISED 8.59 2M 5-62 ATLAS