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FOR OFFICE USE: = (% ------------ ------ ---------------- APPLICATION FOR SANITATION PERMIT Permit No.--------------------------------------------------------- .�.�./------------- -------------- ---------------------------------------- (Complete in Duplicate) ate Issued This Permit Expires 1 Year From Date Issue Application is hereby made to the San Joaquin Local Health District for a permit to c Cfan all the work herein described. This application is made in compliance with County Ordinance No. 549. 4'a 0Q5 (SO--3 C� i JOB ADDRESS AND LOCATION -=• � �1 - �� - "` __t *t - Owner's Name ------.... . ...-'/1101 ._ _ _ Phone.................................... Address------- --•. ........ d ,�� ....-----------•-•---------...........................................•.......................................... Contractor's Name.,�------------------------------•---------------------•-------.._....._..----- -------- Phone................................... Installation will serve: Residence In Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: A---- Number of bedrooms .....!_. Number of baths ---1... Lot size --- _�k__�.`r5..................................... Water Supply: Public.system ❑ Community system ❑ Private 5j Depth to Water Table T7_D_ ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe ❑ Hardpan i Previous Application Made: (If yes,date----- --------) No ❑ New Construction: Yes El No ❑ FHA/VA: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) ^fi I SPptic'Tank: Distance from nearest well___ZC3......Distance from foundation____I?..........-Materiel..u1mrA. ........................... ® No. of compartments------�-------------4_Size. !trX___ -.----.---Liquid depth__..4-------------------Capacity.10 .........-. Disposal Field: Distance from nearest well__ ________.Distance from foundation_-_I_'D_...........Distance to nearest lot line............ ® Number of lines__________Z__.___ -_____-_Length of each line____:�4-_! 49........Width of trench___2_ f----------_............ Type of filter material. _1A._-__.Depth of filter material____I_ _"___-_--__Total length-----I.RA.............................. Seepage Pit: Distance to nearest well----------------------Distance from foundation.................... to nearest lot line................. n ❑ Number of pits----------------------Lining material-----------------------Size: Diameter.__....................Depth-------•---------•--._.--------_. Cesspool: Distance from nearest well_________________Distance from foundation--------------------Lining material------------------------------------- �A ❑ Size: Diameter.--• -----••----------------------Depth----------------------------------------------------Liquid Capaci#y---------------------------gals. k Privy: Distance from nearest well---_----------------------------------_---------Distance from nearest building____-_____.__-____________-___.__.__--_--- ❑ Distance to nearest lot line------------------------------------------------------------------------------------------------------------._................................ Remodelingand/or repairing (describe):------ -------•------------------------------------------------------•--------•-------•---------......._.._...........-----••-----......... ------------------•------------------------------------------------------------------ •--------•-------------------------------------------•------------------------------•------•-------•-------------•--------------- -. i .•--•--••-----•-•------------------------••...---••------•......•.....-•-•---••-•-•------ ...........--........................ ........................... -----------•-----------•------------------------------------- -•-•-------------•-••--•-•••-••.....-------------•...--------------------------------------------------------------------------............................. I 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 regulations of the San Joaquin Local Health District. (Signed)y ✓ �' ` ------------------------•--------------------------------.......(Owner and/or Contractor) .� $y:------------------------------------------------------------------------------------------•---......-----.._..._-------------------(Title)-.------------------------------ —(Plot plan,-showing-sire. of lot,-location of system in relation to wells,-buildings;etc:;can,-be-placed-on-reverse-side). f FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY_____ -G�n.y,�_sr44---------- ----- ---------------------------------------- DATE-----A--L�--1-a'--------------- ------------- REVIEWEDBY------------------- ...... --------------------------------------------•-------•---•-------•---------------- DATE---------.--_-.-------------------------------------------- iBUILDING PERMIT ISSUED------ ---------------------------------------------------------------------------------------------- DATE----------------------------------------------------......... Alterations and/or recommendations-----------------------------------------------------------•-------------------------------------------------.................................................. ........................•--------------------------------•------------- --------------------------------------•------------------------------- ..........._.. --•-------......_.......................... 3 f FINAL INSPECTIONBY -rt ' Date__//-_ �5� .Y-------------------------------------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 114 Sycamore Street 205 West 9th Street Stockton,California Lodi,California Manteca,California Tracy,California ES 9 REVISED 8-89 YM 8.61 ATLAS ti