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g j FOR OFf1GE USE:/ _ ----------'------------------------------------ APPLICATION FOR SANITATION PERMIT Permit No. .. . (Complete in Duplicate) Date Issued ----------------------------------------------------- --. This Permit Expires 1 Year From Date Issued _-_--- --...7-•.� 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�Orrdinanncce�'No. 549. JOB ADDRESS AND LOCATION._.. i! ---(f -C�.�•c ,-W----- ----------------------•--•-•----•-------------------•-•---•-------- Owner's Name .lA ...................... Phone.. --..----- •--•-----_-------- Address.................. -- p...._.. Contractor's Name ?. ----------------------_--------------------- Phone...-------------------------------- Installation will serve: Residence Apartment House ❑ Commorcial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: .__.__ Number of bedrooms ____Plumber of baths _ ----- Lot size .._ _x.l.p.i?__--------------------_________ Water Supply: Public system 9--ifommunity system ❑ Private ❑ Depth To Water Table 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 U�' New Construction: Yes ❑ No [5r' FHA/VA: Yes ❑ No E�' TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Sept' Distance from nearest well-----------------Distance from foundation___________________Material------------------------------------------------- No. of compartments---------------------- _Size----------•-----------------...Liquid depth------- ------------------Capacity � Distance from nearest well----- Distance from foundation. /A_r_._......Distance to nearest lot line.lS.-.�__..... �/ Number of lines___________ Length of each line___ s ( _ O t Width of trench..._.. /�" ................ �l Type of filter materiall. 7/ ._I(_--__Depth of filter material....t.�r............Total length------X0. -—------------------ Seepage Pit: Distance to nearest well__ __ ____________Distanom foundatio .� n... 0-----------Distance to nearest lot line_ ../._.... Number of pits---------I-----------Lining materia__ QG-�-------Size: Diameter_.--••_ _••--_-------Depth__,pZ.U___._-----------•_.. Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material----------------------------.______-- ❑ Size: Diameter------------------------ ------Depth------------------------------ ---------------------Liquid Capacity----•-•-•---.-------------gals. Privy: Distance from nearest well--------------------------------------------------Distance from nearest building------------------------------------------ 0 Distance to nearest lot line---------------------------------------------------------------------------------------•----------.-----------------------------------•-------- Remodelingand/or repairing (describe)--------- -----•---------------------------•-•------------------------•---------•••••----••-••------------------_..---------..-----------------------•---- -•-------•-------•------•--•-------•--•---------------------------------------------------------------•-------------------------------••-------------------------------------------------------------...---------------- hereby certify that I haveaonof M pplic ion and that the work will be done in accordance with San Joaquin County ordinances, State laws, and ruleI s of a San J aquin Local Health District. (Signed)----------------------- --- ---- :-- (Owner and/or Contractor) By:_...................... ----- --------------------------------------(Title)---- ---- --- ---.._.__---------- (Plot plan, showing size of lot, lste in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED B1L�l ---•-----•------------•-- DATE. `--1--------- REVIEWEDBY----------------------------------•---- ------------------------ -------- ------- .. ...._.----------•--- DATE---------- -•-- r/ -----------.............. BUILDINGPERMIT ISSUED.................. --------------- DATE-------------------------------------------- ---•----------- Alterdfions and 1" _. _ = ------------------------------------------------------------------------------------ or recommendations:__ / --------------------------------------------------------------------------------------------------------------------- -------------------------------------------..._..----.....----------------------------------------- ------------- ---------••--•-•------- ----- - --- --------- ---------------- ----- -------------------------------- ------------------------------- -----------------•............... FINAL INSPECTION BY:.---------- Date SAN JO QUIN L CAL HEALTH DISTRICT 130 South American Street 300 West Oak Strout 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,California Monteca,California Tracy,California ES 9 REVISED 8-59 2M 5-52 ATLAS