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FOR OFFICE USE: - Permit No. .... ....... ---------------------------------------------- -__----.-. APPLICATION FOR SANITATION PERMIT ,1 � -••�-- ---------------------------------------------------- (Complete in Duplicate) 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 Ordinance o. 5 9. JOB ADDRESS AND LOCATION:} ._ ___ �. , ...................... ' Owners Name. _•-- Phone.................................... Address_ .. -•-••-----...-•-------•--•-----.•--•---------------•--------------------------------...................................... Contractor's Name---•••..S* . ............�.._.... ._ .---�`-=-------------------------------------------------------------------------------- Phone.................. ---- Installation will serve: Residence [1partment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: _ ... Number of bedrooms Number of baths _._ _ Lot size .� y� f ........................ ; Water Supply: Public system ❑ Community system}❑ Private 0"'Depth to Water Table .094. r Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe ardpan ❑ Previous Application Made: (If yes,date ----- r No New Construction: Yes 2?'Ko ❑ FHA/VA: Yes ❑ No @R,-- ' TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) SP +' T Ik: Distance from nearest well__ /___.____Distance//frrom foundation.., ...__..__.Matsrial____&�/ f!....p ............. No. of eompartments__ ��----------------- Liquid depth___ ��______ Capacity... �f�..... Disposal Field: Distance from nearest` ell.ip . from foundati .>�l .. Distance to nearest I of line.::$7__..... Number of lines....... ....... ____- Leng+hof each line___ __�___ Width of trench._L��....___�.................... Type of filter material _ p ......— 4 g .... .............G . De th of filter matenal_.� _.-�_ ....-_7otal` len th.._.�.:-:fit Seepage Pit: Distance to nearest well--- -----____Distance from foundation....�f cz.Q-_-.Distance to nearest lot _.- ❑+ Number of pits......... . -t Lining Imaterial_ -rte-__.Size: Diameter...... _.3.1!----Depth.... ----------- . 11 i Cesspool: Distance from nearest well------------------Distance from foundation------------.____.Lining.material____:___._..___-_________-__-_.._-_._ i ❑ Size: Diameter-----------•-------_----------------!.Depth-------------------- --------------- = L"iquicl Capacity---------------- -----------gals. Privy: Distance from nearest w,ell`_"-------------------_-______--____.____________._Dunce from nearest building___________-._______._.--------..__._.___. ❑ - :_ .. Distance to nearest lot line.-- --------• ` -' - € Remodeling and/or repairing (describe):--------------- . .......•--.. ...... ... ------------------------------------------------------------------------------------------------------•------_--------- -------------------------------------------- ------- ----------------------------- - - -------------•--------------7------------------------------------------------------------------------------------------------------------------------------------•- I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State laws, d rules and regulations of the San Joaquin Local Health District. Si ned ----- _ __ r Contractor ------------------------------------- -- -- ay:. -•-•-•-----•.............•.._.._._-_••-------------------- -- --------------------Irtle) �` ----------------------------- (Plot plan. showing size of lot, location of system ' elation to wells, buildings, etc., can be placed on reverse side). OR DEPARTMENT USE ONLY t APPLICATION ACCEPTED BY - - -----------------`----- DATE -----rd---- - ----------------- REVIEWEDBY---------------------------------- -•--•-------------------------------------------------.------------------------------- DATE............................................................ BUILDINGPERMIT ISSUED----------------------------------------.------------------------------------ ---------------------- DATE-------------------•--------------------------------------- Alterations and/or recommendations: --------------------------------------------------------------------------------_--------.........-------------------------------------- i ....................................................•---------•----------------- •------•----•----- -------------------------------------------------------------------------------------------------•------•---.._.._--.... ---------- --------------------------------------•------•-•-------•----•---•-----•-•---•-....---.......----•-------•---•----------------------------------- -----••---------------------------------------------------------------------- -----------------------------------------------------------------------------------------------------•-------•--------------------------•-------- -------------------------------------------- ---------------------------- ----------------------------------------------------- ...---------------------------------------------------------------------------------------- FINAL INSPECTION BY:.. ------------- Date------.-------- E - Gam?-�---•- ----- -------------------- i SAN JOAQUIN LOCAL HEALTH'DISTRICT 130 South American Street I 300 West oak Street 124 Sycamore Street 205 Wert 9th Street i Stockton,California +i Lodi,California Manteca,California Tracy,California ES 9 REVISED 5-99 2M 6-61 ATLAS 9'�