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FOR OFFICE USE: yy --------------------------------- APPLICATION FOR SANITATION PERMIT Permit No. .-- .__ ...._.. ... .._ (Complete in Duplicate) / --------------------- ------------------------ This Permit Expires 1 Year From Date Issued Date Issued ._:_.__1.Y_.._ �' 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. 549. JOB ADDRESS AND OCATION----)7- /,1 - •-- --- -- -•-------------------•---------------•--•---- Owner s Name----••A-., � - --•�---�.-----/. , _ t --------------------------------------- s --•- Phone.................----------- -• -- P . ........... �`Address.................................. Contractors --- --- ---/- _ .-------- IM-. Installation will serve: Residence ❑ Apartment House ❑ Commercial $ Trailer Court ❑ Motel ❑ Other ❑ V Number of living units: -------- Number of bedrooms -------- Number of baths I--• Lot size ��--------------------•-•------------------- Water Supply: Public system ❑ Community system ❑ Private q Depth to Water Table 4a_-- ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam 12 Clay Loam ❑ Clay ❑ Adobe❑ Hardpan ❑ Previous Application Made: {If yes,date____________________1 No New Construction: Yes, No ❑ FHA/VA: Yes ❑ No ❑ JTYPE OF INSTALLATION AND SPECIFICATIONS: (Nowseptic'tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tank: Distance from nearest well-I. .........Distance from foundation__/_O-------------Mat rial_______ ______ ® No. of compartments----3-------------------Sizes`M'_ _'_.3 ---Liquid depth____-Y- ------------•-Capacity- -{ - ----� Disposal Feld: Distance from nearest well__t'_y°--------Distance from foundation.,;f............Distance to nearest lot line.__.>�'....... Number of lines_________1_ ____________________Length of each line--- _ ------------Width of french....�-�f_ ..................... Type of filter materiaiu__ -Depth of filter material_If.?'!------------Total length----/fit!-___._-•--_. Seepage Pit: Distance to nearest well---------_------------Distance from foundation....................Distance to nearest lot line____•-------__.-- [] Number of pits----------------------Lining material-----------------------Size: Diameter------------------------Depth--------------------------- Cesspool -----._..._--.--.-------- ...Cesspool: Distance from nearest well______________ _Distance from foundation----------------------Lining material--------------.--------------......... ElSize: Diameter----------------------------•---------Depth----•------•-----------------:----------------------Liquid Capacity..................... ---•-gals. -------------Distance from nearest building Privy: Distance from nearest well---------------------------------- -- g--------•----•--------------••-•---------- ❑ Distance to nearest lot line--------- ---•----------•---•----------t----- --------•-----------.--- -------------------------.........-----•--------------------•-------- Remodeling and/or repairing (describe)___________________ >------" •.---•-•--•-- -•---•--------•---------------------------------- -----•--••---------------- ----------------------------------- -------------......-------•----••�•----------•---•-------...... - -----------------------------------•--------- ------------------------------.------------------------------------. -------------------------------------------------------------------------- I ---•-•-----..----------------•----------------. .I hereby certify that I have prepared this application and that the work•will be done in accordance with San Joaquin County ordinances, Stat laws, and.rules and regulations of the San Joaquin Local Health District. } (Signed}--- •- _-- - --- ----- -• ------- .... __ -'�►-"-4'C•��-�------ ------ ........... 77...-.. --Owner and/or Contractor) (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on revorse�side). Y 4 = FOR DEPARTMENT USE ONLY 0 APPLICATION ACCEPTED BY —3-----�.�------------------------------ REVIEWEDDATE BY------••----------------------------------------------------•---------------------------------------------------------------•- DATE-------------------------------•---••----------------------- BUILDINGPERMIT ISSUED------------------------------------------------------------------------ ---------------------- DATE------------------------------------------------------------- Alterations and/or recommendations:---------------------------------------------- ------•--•-•---------------------------------••-•--•---•--•. ---�-7 s _________________________I-----------___ ._____.____ _._.- _. ._-___ _..._._________ ________ _ _-__ _- --_ -------------------------- ------ _.._.._......._._..____.._____._. ..........................__----------------- ___ ___ _______________________________________ ___________________________________________------_-------------------------________________! ------------------------ ----------------------------- ------------------------------____.....................................-. -----------------------------------------------.--___-_______________ FINALINSPECTION BY---------------------------- -----------------•------------•--- Date------------------------------------------ •----------------•------------------ SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 Wotl Oak Street 144 Sycamore Street 205 West 91h Slrsof Stockton,Coiifornia Lodi,California Manteca,California Tracy,California i E6 9 REVIBEa s-59 PM 5-61 ATLAS