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' FOR UFFWECUSE: 11141 �Pw .-- _C,. APPLICATION FOR SANITATION PERMIT Permit No. ....1.�..._�_� �/ F --------- ------ ----------- ---------------- (Complete in Duplicate) i ti ----------------------------------- --- --------- --- 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 No. 549. JOB ADDRESS AND LOCATI ... 1 a �' ................ •-------------------------...................................... Owner's Name ... Phone-- 4 Address.._Z"... _. .....a --- ---- ---------/........ Contractor's Name____ __ c............ Phonel,14 Installation will serve: Residence A rtment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: 1.... Number of bedrooms _Y__- Number of baths ---/-. Lot size ___ ,, './ ?.�}__________________________ Water Supply: Public system Community system ❑ Private ❑ Depth to Water Table .0�t- Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adob,9N Hardpan Previous Application Made: (If yes,date--------------------1 Noj[ New Construction: Yes No ❑ FHA/VA: Yes ❑ No_ARL lo- TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) nk: Distance from nearest well-________________Distance from foundation--------------------Material--------------------.. ........................... No. of compartments--------------------------Size--------------------------------Liquid de th--------_.------------.._Capacity------•--•............. 4_4e� isposeI field: Distance from nearest well_________________Distance from foundation...........---------Distance to nearest lot line................. Number of lines----------_----------------------Length of-each line.-----------------------------Width of french................................... Type of filter material._..-_..________________Depth of filter material-------------.___......Total length____...._.....__.___._____---_-._-_-___--- Seepage Pit: Distance to nearest well__�=-ate--------Distance from founds#ion__ J Distance to nearest lot line-____✓`-�__... . 19 Number of its__... __ ._Linin material-----------------------Size: Diameter__.X,?'v-------------Depth__ Cesspool: Distance from nearest well___..............Distance from foundation--------------------Lining material........______________-•---______._._ ( , ❑ Size: Diameter = Depth-------- --------------------------------------------Liquid Capacity--------------------- ----..gals. "V Privy: Distance from nearest well-------------------------------------------------Distance from nearest building___.__-_____________--__.___-._=.w''=. ❑ Distance to nearest lot line I � Remodeling and/or repairing (describe):__!"=_ _ ____ - ----•----- -------------- .._...--•-•-------•----•-•------------ I hereby certify that I have prepared this plication and that the work will be done in accordance with San Joaquin County E. ordinances, State laws, an rul s and r ulati of he San Joaquin Local Health District. (Signed)... - •----------i ________________(Owner and/or Contractor) = B ....._. = --------------------------------------------------------------- -- ---- (Plot plan, s Size of lot, location of system in relation to wells, buildings, etc., can be placed on rave side). r FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY....`/ --- ----- `------------------------------------- DATE---- ¢-----• — --- 1Z--•-------- ' REVIEWED BY----------------------------------------- ---------------------------------------------------•--------------------------- DATE...-------_--------------- BU I LDI NG PERMIT ISSUED -------------------------------------------------------------------------------.. DATE. Alterations and/ r commendatio%;----------------- ------ -• --------------------- -----• ... -------• •------------•---------- ---------------•-• ---------------------------------------- --- -----•------------- - ----------------•---•---------._.-.--------------........----------_--........----------.". ------------------- --•---------- FINAL INSPECTION BY:____ .-------- - ----- r 2 --------••--. Date ...... SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Strut 300 West Oak Street 124 Sycamore Street 205 West 9Th Street Stockton,California Lodi,California Manteca,California Tracy,California 18 9 REVISED 8.59 2M 5-451 ATLAS - i