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FOROFFICE USE: ----------------- ----------- --------------------------- APPLICATION FOR SANITATION PERMIT Permit No. ..).�.:...:......... -------------------------------- ------------------------ rr ----------------------------- -- ----- -- (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 County Ordinance No. 549. .. �`3T -� JOB ADDRESS AND LOCATI 2 � - �- ---------- • ---•....... Owner's Name----- ----- --- . •----- --- - ----•--••-------•-------------------- --------------------------.................... Phone.......... ...------------------•--• Address.. — ----•---------------------------------------------------•------•---•------•-•-----•----_.... Contractor's Name--•-- �... �a ---------------------------•--------•----------------------------......... Phone./10....321S Installation will serve Residence Apartment House [3hh Commercial E] Trailer Court ❑ Motel ❑ Other [-] Number of living units- __(__ Number of bedrooms ._. umber of baths .../_ Lot size ......,rt -_��.��.�................... Water Supply: Public system ❑ Community system.0 Private J, Depth to-Water Table ........ ft. Character of soil to a depth of 3 feet: Sand❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe ff Hardpan ❑ Previous Application Made: (If yes,dcite--------------------) No ❑ New Construction: -Yes ❑ No [j- FHA/VA: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tank: y Distance from nearest well_________________Distance from foundation....................Material------------------------_....................... ❑ ,P�l s�s�t- jNo. of compartments-------------------------Size--------------------------------Liquid deet------------------------•-Capacity------........../-. Disposal Field: ✓Distance from nearest well-_45-4)__Distance from foundation......1.40_-__.__Distance to nearest lot line---Is._._._.. Number of lines----------/----------------------Length of each line_______-�,�.____________-Width of trench______'cz�. .��...._._.____--- Type of filter materiaLR0_Gf<_______Depth of filter material---J_-C.7_ __--------Total length-------- -___-___________._....__ Seepage Pit: Distance to nearest well----------------------Distance from foundation-----...............Distance to nearest lot line............. ❑ Number of pits______________________Lining material--_-_-__._________---Size: Diameter-----------------------Depth_________.______-_----_______-_.- Q 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----------------------------------------.. ❑ Distance to nearest lot r —�line-------------------------•-----------------------:-.--•-•---------------. . -'--"------------------------•------•--------------------------. -- Remodelinand or re airdesc ..............................•..................... -----------•-•----------•------------------•----. --------- ---------------•-----•--••-•---------- •------------------------- � -------------------------------------------------------------------------------------- ------------------------------- •--------••----•---------------••----._...-.----------------------------••-•------•--------------•-•---------------•--------------------------•------------------------... I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinan State laws, and rules and regulations of the San Joaquin Local Health District. (Signed} '.:__._,_.. -----------------------------------•-•-••-------•-----(Owner and/or Contractor) B : ----------- s - (Title)---------------------•----------------------------------------- (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY_.___0.%_____ --___-_-.--- J__ Z ----------- DATE.... 2- --------- REVIEWEDBY----------------------------------------- ----------------------------------------------------------------------------- DATE----------------------------------------------------------- BUILDINGPERMIT ISSUED--------------------------------------------------------------—-------------------------------------- DA•TE----------------------------------- Alterations and/or recommendations:------------------------------------------------------- ---------------Z:............................................ -----••........... --•---•------------- - ----------- --------- ------------_------- -------------- a- _..__._....-•-••...--•--_.. .......... ,, ...� ,t {: - !J : . , - � FINAL INSPECTION BY:-- .. • --- -- • - --------- Date-----/ --------•- ------------------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT . 130 South American Street 300 West Oak Street 124 Sycamore Street 205 West 9th Street `- StOCktenr California Lodi,California Manteca,California Tracy,Calif*rrnia ES 9 REVISED 5.89 2M 8-61 ATLAS