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FOR OFF SE: !� 'APPLICATION FOR SANITATION PERMIT Permit No. . _. ... ------------------- Com tete in Duplicate) �8�d —t9S'S s - - -------- ---------- � P -- -- ------• -- ------------- �•t t , .... __Z:�.lo. 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 descried. This application is made in compliance with County Ordinance No. 544. JOB ADDRESS AND OCCATIIO --------------- - ------------ ----------------- -------------------- ---_ C� / Owner's Name- Address ame_ Phone_... Address-------•----------------- - --- -------------- ----__ ---- •---------------------- •---.. � ' Phone. Contractor's Na �/-�J� ---- - -- -�--- • - rt-- -- --•--- ----•-• ---- Installation _�. will serve:. Residence i a�t House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ I Number of living units: ._�Num o bedroom--_ Number of baths __ at size _ _.�. --./..+� ••-• Water Supply: Public system . ommunity system ❑ Private ❑ Depth ro Water Table _0—CAt. Sand Loam Clay Loam ❑ Clay ❑ o s ardpan ❑ Character of soil to a depth of 3 feet. Sand ❑ , Gravel ❑ y ❑ y El Previous Application Made: (If yes,date....................) No ❑ New Construction: Yes ❑ No FHA/VA: Yes ❑ o TYPE OF INSTALLATION AND SPECIFICATIONS: o septic t r cesspool permitted if public sewer is available within 200 feet.) b ptic n Distance from nearest well----------------- from foundation. ___________________Material_.________...__.___.._._____......._________..... o. of compartments ---------------Size----------------------- ------Liquid dept----------_---- ....Capacity---•-•----------•-----i npo F � Distance from nearest,well„�___fi0._._Distance from foundation____ l-9..._..Distance to nearest lot line____. ------ Number of lines_1i ______________ _____Length of each line__Q5_c4_._�_.______.Width of trench___..�_l`✓�_�!.-.-___-.. R , � �� Type of filter material { _Depth of filter material_-_-____-/9_f�_Total length___:__4�__ ----------------- �i'� r /-p`____..Distance to nearest lot line...__.__ age 1� Distance to nearest well-1-0-0--1__.____Distance rom foundation______ Number of pits.---it---------------Lining material--K-0- _.____.Size: Diameter__. _�__Depth_._,Z�`----------.: ss 30� Distance from nearest well----_------------Distance from ounclation-------------------.Lining material-___.______- ------------------ ... Ce p ❑ Size: Diameter--- ---------Depth_Depth_,--------------- -------------------------------Liquid Capacity gals. i I Privy: Distance from nearest well----------------------------------------- -------Distance from nearest building------------------------------------- .. ❑ Distance to nearest lot line- --------------- ---------------- --------------------------•------.--------------------------------------------------------------------- I k Remodeling ---------------- ----- Remodeling and/or repair escribe�------ X--------------------------------------------------•-------•---------.... J k - ---------------------------------------------------- -- ---------------- --------- ------ - ----- i - - ---- - - -- - --- - ------ - ----------------• - ----------------------- ---------- ----------------------------Vcc ---------------------------------------- hereby certify that I have prepared this application and that t e work will be donente with San Joaquin County ordinances, S. la and rules an a ulations f t e S Joa 1 th Di ric--- -- - ------ -- (�9rSi reed -- - .-- ---- Contractor) i 9 �] ,g ---------------- By---------------------------------------------------------- -f *- RC1- - ----(Title) (Plot plan, showing size of lot, location of system in relation to s, buildings, etc can be placed an reverse side). .r FOR EPARTMENT USE ONLY APPLICATION ACCEPTED BY_.��_ . .. _ - -- -- ----- ---- -- ----- -------- ------------- DATE---�/ ------------------------- REVIEWEDBY--------------------------------- ------ - ---------------------------------------- DATE-- --------------------••---••------------- BUILDING PERMIT ISSUED------------------------------- ------ ---- - ------ -- -------- DA-TE------------------------------------------------------------- Atterations and/or reco endation01 s:_. ----------•---------- - ----------I------••--•--------------------------.----------------------- --------------------- I --------- --- ------------ -------- .---------._._.... FINAL INSPECTION BY:../. ._ -__ ----- -- _-- Date--- t/__. ----- •-- --- r +? SAN JO UIN LOC HEALTH DISTRICT I 130 South American Street 300 West Oak Srreef 134 Sycamore Street 205 West 9th Street Stockton,California Lodi,California Manteca,California Tracy,California ES 9 REVISED B-59 2M 5.62 ATLAS