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FOR OFF dCEE USE: -- �_4 APPLICATION FOR SANITATION PERMIT Permit No. ... ............ / ------------------------------------------------------ (Complete in Duplicate) Date Issued •_�jA_3 ---------------------------------- --- 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 compliarice with County Ordinance No. 549. ----- __ ................OB177.� 71!�1��.. .C /_Y17� T•17 ../�T JADDRESS AND � ION... p� Phone---------•---••-------------------- Owner's Name..... --/ -------- Address............... - - -••-;--- ---------_-------------•-.-------------------------------------------------------------------------------------------------------------------------------------- Contractor's Name-------.----y___-- - - Phone.. Installation will serve: Residence M--A--partment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: Number of bedrooms 9-- Number of baths -----_.. Lot size _- —�----------------- ----------- Water Supply: Public system (3 Community system ❑ Private[�epth To Water Table ft ' Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam Clay ❑ Adobe❑ Hardpan ❑ Previous Application Made: (1f yes,date--------------------) No ❑ New Construction: Yes ❑ No ❑ FHA/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.:-_-----.--------------------------------------- A� J"✓ji(� lle No. of compartments----•------------------_- ize-----_------------------------Liquid de�h--------------------------Capacity--_---•-•----------- DisposalcFieid� Distance from nearest well.-4/�_e._Distance from foundation--20----_---.Distance to nearest lot line................. K`� y Number of lines.-------�---i---- ----- Length of each line---f �_______________Width of trench- --.-----_--_-------•-------_ y —/ Type of filter materiaL1 .Depth of filter material f -.--------Total length �� Seepage Pit: Distance to nearest well-_-_. 1C�--Distance fr m fo dation--._.___Q._�...Distar�e to nearest/link---------------- �� Number of pits--- /-----------Lining material__,) _Size: Diameter.-%_-?J-----------Depth_ _-ss0 .------------------•• Cesspool: Distance from nearest well-----------------Distance from foundation.-------.---- ----.Lining material..----------------------------------- i ElSize: Diameter--------------------------------------Depth----------------------------------------------------Liuid Capacity ----------------gals. Privy: Distance from nearest well .----------------------------•--------------------Distance from nearest building-----.----------------- ----------•---- ❑ Distance to nearest lot line----------------- - - 11-1 - w Remodeling and/or repairing (describe)------------------------ = �1r---------- ------------------------=------------------------------------------------------------------------Ad- ...... --------- ---------- - --- -- -- -- - --- --- ---- -------------------.--------------------------- ---------------------------------------•--••--------------------------------- I hereby certify that I have prepared this application and that thb work will be done in accordance with San Joaquin County ordinances, State laws, and rules Ind regulatto s of the San Joaquin Local Health District. t (Signed) ---------------- (Chmmr for Contractor) By --------------------------•---------------------•----------- '---------------(Title).6 �' --------_--- -------- (Plot plan, showing size of lot, location of system i r ation to wells, buildings, etc., can be placed on reverse side). p_ FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY----0.--F- ?�S - ---------- DATE----- l REVIEWEDBY------------------------------------- ...-------._ DATE------------------------------------------------------------ BUILDINGPERMIT ISSUED---------------------------------------- ---•-- DATE----_------------ ------------------------I------------------- Alterations -- -----------------•-------------------- Alterations and/or recommenttations---------------------------------------------- ----- -•----------------•--------------------------------------------------------....-------- ••---•---------------•--•-------------•------•---••---------- FINAL INSPECTION BY:------- .-'----- ------------------- Date--- ' �� ------ --------------- ------------ ---------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Strut 300 West Oak Strut 124 Sycamore Street 205 West 9th Strut Stockton,California Lodi,California Manteca,California Tracy,California ES 9 REVISED a-59 2M 5-62 ATLAS