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FOR OFFICE U E: - ..... -_-_... '-----..---- ��-�:-.-__-- ..' APPLICATION FOR SANITATION PERMIT Permit NO: 1..4.f?.L2M ----------- --- -•------ -- ------------------------ (Complete in Duplicate) Date Issued �....:f.�.:.�.� -------------------------------------------- ------------- 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 . S49. �y� JOB ADDRESS AND O ATION___ Q --- �"--- -_ -- _ f '`� -- --•... ..... ...... -- --- ` 0 TT�`' d�sez. Owner's Name......... ---•-�--�--------- _-.. Phone-------------•-•----- --- ---------•----•--•------------------------------------------------- ---------------------------------------•- Adaressp .....--•- -•-• --1 �--------�-------- ------------------------- ------------------- -------------------- ------------ ...------- . ------ Contractor's Name -------t------- ----------- ---• ------------------------- Phone....----...... Installation will serve: Residence ❑ Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Sa x ��-� J.... � Number of living units: ._i...-_ Number of bedrooms �. Number of baths .-1_--- Lot size ...:....................................................... '. Water Supply: Public system [Community system ❑ Private ❑ Depth to Water Table f,-ft. Character of soil to a depth of 3 feet: Sand Gravel ❑ Sandy Loam ❑ Clay Loam 0 Clay ❑ Adobe❑ Hardpan ❑ � Previous Application Made: (1f yes,date--------------------) No New Construction: Yes Eq--4o❑ FHA/VA: Yes ❑ No EA-- TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic nk: Distance from nearest welly----_-Distance from foundation.../�.............material........I-------------------- ..---.- No. of compartments_--_2-__--_-____..--.-Size...._._.. XS-x` ._--Liquid depth------ ---------------Capacity.... . ' Q i Disposal Feld: Distance from nearest well'.-L------Distance from foundation... a---_....._.Distance to nearest lot line..�..7...... Number of lines__--._-____. _----_--_-----Length of each line_-_-.- � _. Width of trench----__ -z_�-'-----.._-.. . GlC - -- .. Type of filter material----- -------------------Depth of filter material- -1.- -------------Total length------------------k0_1_-..•._._---._ Seepage Pit: Distance to nearest well--------------------- Distance from foundation....................Distance to nearest lot line----------------- E] Number of pits----------------------Lining material----------------------.Size: Diameter--------------------- Depth................................. 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 line-----------------------------------------------------------------------------------------------------------------------...........-_-----.-.. Remodeling and/or repairing (describe)-------------------------------------•---------....-.-------•-----•---•--•-----•-------•-----•-----•--•-.-.-...----•-•----------------•--•---------------- n •--•------•-....................................................------------------------------------------------------------------------------------------------------------------------------------------------------------- --------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------•----....-----------•---------------- ------•----•---- ---------------------•------------.-..................---------------------------------••---------•------------------------••----------------------.-....----•----------------------------------------------- ! hereby certify that I have prepared this application an that the work will be done in accordance with San Joaquin County ordinances, State laws, and rules and regulations oXtaJoaquLocal Health District. (Signed)-----------------------------------------------------•-- ----------- ----- -------------------------------• •----------•-----------------{Owner and/or Contractor) sy:.- --•--------- ----- --- -------------------------- (Title) --------------------------------------------- ----------------- --------------------------- plan, showing size of lot, location of system in relation to ells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT /USE ONLY APPLICATION ACCEPTED BY----------------------------------------------------------•--.---t- --- DATE-------------fes- f� ------------------ REVIEWED ------------ -.REVIEWED BY------------------------•-------------------• ------------------------------------------------------I,-------------------__ DATE ---- BUILDING PERMIT ISSUED--------------......................•--...-----------------------...............-- .----•------.... DATE----------------------------------------------------------•- Alterations and/or recommend'ations:--------------------------------------------------------------------------------------------------------------------------------------------------------------- -------------------------------------------------------------•-----••-----------------------------------------------------------------------------------------•...._----------------------------------...---• --------------- ----------------------------------- ---------------------- -- --- - ---------------------------------•---------------------------------------------------------------------------------- •- --------------------- t� - 1 - ----- FINAL INSPECTION BY:.. �flate ` � ------ •-• ------ ------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 Wetl Oak Street 124 Sycamore Street 205 West 91h Street Stockton,California Lodi,California Manteca,California Tracy,California ES 9 REV16EO a-59 EM 5•51 ATLAS r