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F R OFf ICE USE. ----------------- ------- - -- --- APPLICATION FOR SANITATION PERMIT Permit No. _45 1.2-- (Complete in Duplicate) 11.2- ------------I-- ----- ------- --- ---- - -------------- -------------------------------------------------------- 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 Ordain e No. 549. i 77 JOB ADDRESS AND LOCATI N__. Q[ - �7R �7------------ ------ --•--••--------------------- ----•- i` Owner's Name.......le ,+-------- ------- ------------ -- ------ ------ ---------------•-------•----------. -. Phone/ym.._ - Address-_ ...... .. -- ----------.-A-- - Contractor's Name-.---- --�it...... --------------- Phone.N�.6.... q 4.N Installation will serve: Residence P( Apartri ent House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units:..... Number of bedrooms _CZ-_ Number of baths __L Lot size 1._�v_......................................... Water Supply: Public system ❑ Community system ❑ Private 0 Depth To Water Table y-5_ ft. Character of soil to a depth of 3 feet: Sand [] Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobeo Hardpan ❑ Previous Application Made: (If 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-6. -Distance from foundation____ ---�?....._-.M ial..._/ No. of compartments____ -----------------Size_> $� _ ..___,___Liquid depth___ e_ ................................. .- __Capacity._. _.. .. .... Disposal Field: Distance from nearest well___—---4'.-Distance from foundation.. ....Distance to nearest lot line__ ____---- ___ - Length of each linee _____:__fat __.-Width 'of trend{_*. ��_______________`___ Number of lines....._____ __ Len Type of filter material.-S i�?ok: j_Depth of filter material___-/ -------Total length_._ ................ Seepage Pit: Distance to nearest well---------- ---------- from foundation....................Distance to nearest lot line_______________-- } F ❑ Number of pits----------------------Lining material-----------------------Size: Diameter----.--.-------------- Depth---------------------------------- Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material--_-______________-___________._._-_ ❑ Size: Diameter--------------------------------------Depth--------------------------•-----------•-----.--_--Liquid-Capacity--------------------•--•----gals. I Privy: Distance.-from nearest well_________________________________________ _______Distance from nearest building.____.-____________-___-------------___-_. ❑ Distance to nearest lot line------------------------------------------------ --------------------------------------A-- ---------------------•---------------------•------ I Remodeling and/or repairing (describe)--------- ------------------------------------------••----•-------------••-•---------•------•-- ---------------------------------------------- -------------------------------------- .- --------------------------------------------•-•------------..._._._..---------------------- -------•-----1--------------------------..-------._....._...------------------•-•--------------•---------•-----•----------------- hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, t laws, and and regu tions of the San Joaquin Local Health District. (Signed)------ - -,-fs .............- -----UDwner and/or Contractor) By: [.�[� - --- --- ---------------------------------------{Title} F (Plot plan, showing.size of lot, location of system in r 10 to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY-------- -------- --•-•-----•----------•-------------------- DATE-- .--"- --2 -2-------------- REVIEWEDBY---------------------------------- ---------------•------------------------------------------------------ DATE------------------------------- --------------------------- BUILDING PERMIT ISSUED.---...._-•----------------------------------------------------------- ----------------------------- DATE------------------------•------ Alterations and/or recommendations:------------------------------------------------------------------------------•-----------....._._..-•---------------..--------- - --------- ...- ... -----------------------------------------------•-••------------------------------------•------------------------------------•--•---.----••------•-•-------__------------•---••---------------•-----------......-------------- --------------------------•--•-------- ---------------------------------------------------------- -•------------------------------------------------------------------------------------------------------ ------------------ FINAL INSPECTION BY:... R - ... Date- /-_ -- ey SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 124 Sycamore Street 205 west 9th Street Stockton,California Lodi,California Manteca,California Tracy,California ES 9 REv15ED a-59 2M 5-62 ATLAS