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FOROFFICE USE: -----------4------------------------------------': "APPLICATION FOR SANITATION PERMIT Permit No. :- ---------'---------------------------------------- (Complete in Duplica+el ------------------------------- This Permit Expires 1 Year From Date Issued Date Issued LG_:?-5-� -- 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. i JOB ADDRESS AND TION 6 !/ - ` .0/ - ------------•---•••....... I Owner's Name 4---` ---- -- -. II• -------- Phone Address-----............... ------- ----------- ---• -------- ------ •------------------•------------------•---------------•---•---------- ----------- - ---•-- ------ --- Contractor's Name -------�i- ��--- Phone -------••- Installation will serve: Residence ❑ Apartment House ❑ Commercial ❑ Trailer Court 0-- Ivly otel 0 Other ❑ Number of living units: -------- mber of bedrooms -------- Number of baths -------- Lot size Water Supply: Public system Community system ❑ Private ❑ Depth To Water Table __4q ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe E!T'Hardpan ❑ Previous Application Made: (if yes,dote....................) No �New Construction: Yes �o ❑ FHA/VA: Yes ❑ No TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic or cessti.00l p'rmitted if public sewer is available within 200 feet.) an �� Distance from nearest well--- - ..Distance from Cgs foundation_ f_e------•--.Material--_-_ �No. r ---_-_ j _ of compartments....../------------------Size.�,K_ _�............Liquid depth_-----�-- -- Capacity.`Z --- .Disposal Field: Distance from nearest well______ ________Distance from foundation.....__-____-__-___-Distance to nearest lot line................. ❑ Number of lines-----------------------------------Length of each line-------------------------------Width of trench.----....------------•-•- - F Type of filter material--------------------------Depth of filter material-------------------••--Total length ------------------------------------------ Seepage Pit: Distance to nearest well----------------------Distance from foundation...-----------------Distance to nearest lot line-,--------------- 0 lNumber of pits.--`------------------Lining material-----------------------Size. Diameter------------------------Depth Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining ❑ Size: Diameter-----------------------------------Depth--- --- ---------------------------Liquid Capacity .gals.I Privy: Distance from nearest well____________________________ _--_-_-__-_Distance from nearest building.-_. ❑ Distance to nearest lot line---------------------- ---------------------------------------------------------------------------------------------------------•-----•-------••-------•--•------------------------------•---- p. ------------ �Remodeling and/or repairing (describe):______._.- . vd /y 7 �,rf ---------------------------•- ----------....'------••----•-------...._.____._.--------- - -------------------------------------------------------------------------------------------------.--------------------------------------------------------•--------------------------------------------------------------- - I hereby certify that I have prepared this application and +hat the work will be done in accordance with San Joaquin County ordinances, State laws, and rules and gula+ions of the San Joaquin Local Health District. (Signed)--------------------- - ---- ----- ---- - ---- - .----------(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 DEP TMENT USE ONLY APPLICATION. ACCEPTER BY t= ------ DATE.............. `.�. REVIEWEDBY------------------------------ -------------- -------------------------------------------- -•- ---------- DATE-------•------------ - -------------•----- _ BUILDING PERMIT fSSUED--------------•-------------- ------------- DATE----;-----------•----------- Alterations and/or recommendations:------------------ ------------------------------------------------------------- -••------••----------••-----------------------•----•• ------ t { FINAL INSPECTION BY:.. Z1 -.y—.�— Date--------- SAN JOAQUIN,LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Smoot 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,California Manteca,California Tracy,California ES 9 REVISED 13-59 2M 5-62 ATLAS