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rVK%arrik_r uar ----------------------------------------------------- ------------------------------------------------------ APPLICATION FOR SANITATION PERMIT /��`Permit No. .__/--- ------------------------------- ------ ------------------ (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 ounty Ordinao. 549. k JOB ADDRESS AN OCATION__---------- -- � -- ....---••-•.................. .......• 4�" Owner's Name jAment ��L.�_ -....__ Phon ................................... Address - ------------------- -••------- Contractor's Name------------------- --•---- -----•------------------------------- - ........-------------------------------------••---• Phone----....................Installation will serve: Residence ❑ House ❑ Commercial ❑ Trailer Court ❑ Motel [3 Other +Kd�- Number of living units: ........ Number of bedrooms -------- Number of baths -------- Lot size _ 3l_ �/ Water Supply: Public system ❑ Community system ❑ Private g Depth to Water Table � ft. Character of soil to a depth of 3 feet: Sand E] Gravel Sandy Loam X Clay Loam ❑ Clay ❑ Adobe❑ Hardpan ❑ Previous Application Made: (If yes,date--------------------I No New Construction: YesOQ.No ❑ ' FHA/VA: Yes ❑ NO'K TYPE OF INSTALLATION AND SPECIFICATIONS: wN41 septic tank or cesspool permitted if public sewer is available within 200 feet.) Dpca k: Distance from nearest well---Z_OO.Distancrom found tion___._. QM ______. jx No. of compartments___j---------------------Size_�jD_.X...�_Liquid depth-------(V-.y........Capacity.aKQ.0...... . Disposal Field: Distance from nearest welL.240.._Distance from fou dation----e ......;Distance to nearest �(l Number of lines...... _ -------------Length of each lit __=f d_-t_J-&idth of trench.....2___-_------__________--_ Type of filter •_-Depth of filter material_a—_7_—'--_30Ao*tal length____ __ _____________________ Seepage Pit: Distance to nearest well----------------------Distance from foundation....................Distance to nearest lot line----------------- 0 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_._______________-----._____________--_. ❑ Distance to nearest lot line-.. ----- Remod..e_liinnrg and/or reep�airjg describe)---------------- --4--j----------------------•-•----------------•-••---•-•-------•---------------------------....................................... .. �'" € �`� Q'r = '-----------•-------•-------------•---••----•---•-----••-----------......--------------••-----------•---------------.------ ----------------------------------------- ---------------_______------------------------------------------------------------------------------------------------------------__________________________________ ____________________________________________________ 1 hereby *rfi y,dfhn.atlhve prepared this application and that the work will be done in accordance with San Joaquin County ordinences," ate awl'es and re lations of the San Joaquin Local Health District. (Signed fz ------------------------------------------------------------------------------------------•--•----------------(Owner and/or Contractor) 1 B : ----- --------- ---- --------------------------------------- -----------------------------------------(Title)-----------------------------------._-------------------------- (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be-placed ori reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED SY----------- ---------------------------- _._. DATE REVIEWEDBY---•---------------------------------- -------------------- ---------------------- DATE---------...__...� _.�7,r._ _Y �• f BUILDING PERMIT ISSUED................ -- --- ------------- —---------------....... ................ DAT Acte at and/ recorrlmen of ns:_. e? -A-- h� -• -f -------------------------------------------------------- ....... -------------------------------------------------------------- ------ --- - --- ---------------------------------------------- Date-------- --._Z67��.6-— ---- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 124 Sycamore Stmt 205 West 91h Street Stockton,California Lodi,California Manteca,California Tracy,California £S 9 REVISED 0•54 2M 6-6t ATLAS