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FOR OFC US f APPLICATION 'FOR SANITATION PERMIT Permit No. ../-.. ....... --------------------------------------------------------- ------ ------------------------------ --------------- -- - (Complete in Duplicate) Date Issued .....�,�=_•�.]� ------------__----------------------__ ------------------ 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 compliance with Cou ty Ordinance No. 549. JOB ADDRESS AND®LOCATION ` ------------------------------------ - ---_------------------_- Owner's -- ------------------------ Owner's Name---____-./_C-.---C-------- -----------••----------------------------------- -------------------------------------------- Phone.................................... Address......................_�. -------------------..................... Contractor's Name.............. .. ----•.... f. 17__2 •-- ••• Phone......... Installation will serve: Residence ff'Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑/ Other ❑ Number of living units: ___-1--- Number of bedrooms . ___ Number of baths --L___ Lot size •U' Q_ __/ _____________________________ Water Supply: Public system [�rCommutiity system ❑ Private ❑ Depth To Water Table Zo_. 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-.__...________--__l No lK New Construction: Yes_21/ FHA/VA.. Yes ❑ No TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer.is available within 200 feet.) Septi TanDistance from nearest well_________________Distance from foundation....................Material------------------------------------------------- 6��' No. of compartments--------------------------Size---------------•---------------Liquid depth--------- •----- -------.-Capacity---------------------- Dispos Field: Distance from nearest well------------_.-Distance from foundation....................Distance to nearest lot line................. Number of lines-----------------------------------Length of each line------------------------------Width of trench-------------._-------------------. Type of filter material..-_____________________Depth of filter material---------------.-------Total length__-_------_-----___-__________________..._ Seepage Pit. Distance to nearest well..-_--��----------Distanc�rom foundation-10.............Distance to nearest lot line_ _. Number of pits---.__-_._________Lining material__%1'�Ct..C_ --------Size: Diameter---32............Depth--.- _I___-____.____- Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material__..____-____________----_..._.. ❑ Size: Diameter--------------------------------------Depth---------------------------------------- --•---..Liquid Capacity............................gals. Privy: Distance from nearest well-------_-----------------------------------_-----Distance from nearest build;ng_____._________-___.-_--------____.______- i ❑ Distance to nearest lot line------------------------ ---------------------------------------------------------- ----------------------...----•------------------.----- i A Remodeling and/or repairing (describe)--------------------------------------- ---------------•-•--•---•-•--•------•---------•------------------•------•--------•-------._...-•-------------•--- --•---.....----•................•-•----•-------••-------•-- --------------- ••-•-------•---------------------------•------------•---------------•--•-------- ---------.-_---------- ----------------------------........ -----•----- ---•----•----•---------•-------------------------- ...------ --•------------------------•-•------------••----------------•-------------------•-•-- ----- - 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, and rules and regulat' of a San Joaquin Local Health District. (Signed)......................... -- ---- -----------. ---- ------------ --------------------------------------------••---------------------------(Owner and/or Contractor) B • ----------------------------------•---------(Title)------------------- ----------------------- ................... (Plot ---... ------------/plan, showing size of lot, location of system in ref tion to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY-- --------------- �y ------------• -------------•---- -------•--------•- •---- DATE...... ...................... REVIEWEDBY-------------------------------------------- ----._ ---------••--- DATE------------------------------- BUILDINGPERMIT ISSUED--------------------------------------------------------------—--------------------------------- -• DATE------------------------------------------------------------- Alterations and/or recommendations:------------------------------ -------- ---------------•------- -• ----- ---------- .................... . 3---•-•------0 '` . . . ------.Q�--------------......-.. ----------------------------------------------------------------------------------------------------------------------------------------------------------.._._._..........---•---------------------•---•----------•---------- -----•------•--------------------------------------------------------------- --------------------------------------------------------------------------------------------------------------------------------------------- FINAL INSPECTION BY: 4.-` [at' Date----- 1 ._:_ .�--------- ------ -------------------------- 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 REVISED S-59 2M 5-82 ATLAS 1