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FOR OFFICE USE: ' ------------ -------------------------- --------------- ------------------------------------------ -------------.- ______ ------------- APPLICATION FOR SANITATION PERMIT Permit No. I) ----------------------------------------- --------------- (Complete in Duplicate) .. - ---- - - --- This Permit Expires 1 Year From Date Issued Date Issued ___.... --_V�� 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 No. 5419. JOB ADDRESS AND LOCATION..__?R�- �e _ -__- - �?�/� -------•-00------------- •-------------------------•-• --------------- Owner's Name------ Phone....----------------------------------------------------- -------------------- Address------- � . Contractor's Name----------- -• ----------- -------------------••- ------------------------------------..__ Phone..........................-------- Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: ..-�__ Number of bedrooms ..�Number of baths ____!_ Lot size ----- ---- ��_ -�C�-_-_-_--__. •-----.....-•-- Water Supply: Public system ❑ Community system ❑ Privatex Depth ro Water Table ..6__ ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe Hardpan ❑ Previous Application Made: [If yes date__.._____.___._-_._} No [ New Construction: Yesl❑� No FHA/VA: Yes ❑ No`� J� TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.). Septic Ta Distance from nearest well________________ Distance from foundation__.....____:--------Material______--._____-____.. ____ No. of compartments--------------------------size J---------------_----------,_..Liquid de th__.---------------------._Capacity is osal Field: Distance from nearest well.0��c i tante from foundation__.�_d------Distance to nearest lot line-__� t umber of lines----------/__.-- Len Length of each line_.._._ _Qv rte"--------- g I -----.---- � r--..Width of trench--ii-�'�-...------•---..._ Type of filter materiaL..St'_ Depth of filter material____. _9---__-__._Total length____•_-!�O --...................... Type Pit: Distance to nearest well----------------------Distance from foundation----------J-_______-Distance to nearest lot line_________________ ❑ Number of pits----------------------Lining material-------- -------Size: Diameter-------------------------Depth---------------_-------_-----•-•- Cesspool: Distance from nearest well-----------------Distance from foundation---- __{__-_____.Lining material-------.__.______._.--_____.._....__ t� ❑ Size: Diameter____. ___- 1 •-------- -------Depth-------------------------------------- ------- ---._Liquid Capacity-----------------------------gals. Privy: Distance from nearest well---------------------------------------- _.- -_Distance from nearest building._____ ___.__--.-_________-_. Distance to nearest lot line = Remodeling and/or repairing (describe):---- -----:-:---- -------------r--•------- -------- ---------•----- ------------ r ti - ----•------•--------------•----------••---------------•--- --•- -------------------- •-----•------------------------------------ - hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin-County ordinances, State laws, and rules and regulations of the San Joaquin Local Health District. (Si ned 5 )-------•-(•`�'`-----�--�r-ti"-'�-`-`--------------------------------------------- -------------(Owner and/or Contractor) By:-----------------------------------------------------------------------------------------------------------------------------------(Title)------------------- --- (Piot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). , FOR DEPARTMENT USE ONLY w APPLICATION ACCEPTED BY---------------------------------- ------------------- ----- --- ------•--------•-----DATE----------- REVIEWED BY --------- ----- - DATE---------- Y. _ _ -------•------------- UILDING PERMIT ISSUED------------------------------------------------------- ------------------------------------------- DATE--------------------- ••••- Alterations and/or^_ mendations: ------------------ r-- R ------------•---------------------------------------••----------------- ----------- ----------- I ----------•----------------------------------•---------•--- FINAL INSPECTION BY:--- ------- ----_-------------------- / SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Strut 300 West Oak Street `124 Sycamore Street 205 West 9th Street Stockton,California Lodi,California — —gYja teea,California Tracy,California ES 9 REVISED 8.57 ZM 5-62 ATLAS