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' FOR OFFICE USE:----------------------------------------------------- APPLICATION FOR SANITATION PERMIT Permit No. .cz�.c __a ----------- ------------------------------------ ------------------ (Complete in Duplicate) )) fl8t9 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. > n� JOB ADDRESS AND LOCATION.- --------------------------- ..........:.............................. Owner's Name-------- ---••---•----• -•.-A.....-- ------ Phone........... ..................... Address......__......... r� •------ ---- r r - --- - - -------- •...... ------------------------------•-----••----•-------------••. !" - -._ Contractor's Name..... -- -- r._-- -- _• ...--.-_-__ Phone.._ , '_.a � Installation will serve: Residence Qg partment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: ___—L Number of bedrooms _a_. Number of baths A2--- Lot size ___. ------- ____ ______...____________________ Water Supply: Public system ❑ Community system ❑ Private C9 Depth To Water Table- ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe JX Hardpan F1 Previous Application Made: (If yes,date....................1 No �°, New Construcfion: Yes ❑- No rtr FHA/VA-. Yes ❑ NOA TYPE OF INSTALLATION AND SPECIFICATIONS: ( septic tank or cesspool permitted available � a feet.) Septic TankDistance nearest wel ___ � Qis}anefromfoundaoam 1 _______.___.___.______ = ��-� Liquid depth..... � tNo. of compartments_______.Z_._______.__Size_a��_sYA 5tao."I_ - Disposal Field: Distance from nearest well---aS— ._..._Distance from foundation--/ ._r.....Distance to nearest lot line____+ _...___._ � Number of lines_______.._.a ___ Length of each line_____, _ Width of trench------�.r,�___'�_____.___ Type of filter material.... ___Depth of filter material____ , .��..__Total length_____-, --------------------- e --'_____________ Seepage Pit: Distance to nearest well__ (! -____-Distance fr ' f clation___�Q_____-_-.Distance to nearest lot line-___i�.__. Number of pits______.__________Lining maferial._..A r p -- 1 �' ----size: Diameter--- --`-�-------•---Depth Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material__.____.._..___________-_-__-__-_---- t- ❑ ` Size: Diameter--------------------------------------Depth----------------------------------------------------Liquid Capacity------------•---y----------gals. l . Privy: Distance from nearest well-------------------------------------------------Distance from nearest building________________________-_____._-._-__.._. 1 ❑ Distance to nearest lot line--------------------------------------------------------------------------------------------------••----•-••--------•----------------------- t Remodeling and/or repairing (describe):----------------------------------- --------------- ----------------.................... --.-..-_------------•--------------•-------•--••------------ ------------••--•-------••---•-••------•----•----•--------------------------------------------------------------------------------------------------------•----------------------•------------------------------------------- --------------------------------------------------------------•----------•.----------------------------------.--..------------_-.----------------------------------------------•-•---------•---------------------------- 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. t (Signed)------------------- r __ (Owner and/or Contractorl By............. _..,._.. f Title /! (Plot plan, showing size o:�f lot, I cation of stem in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTEDBY � " DATE___ _,✓ -_ _'7__________________________ REVIEWEDBY--------------------------------------------- --- DATE------------------------------------------------------------ 'BUILDING PERMIT ISSUED-----------------------------.------------------------------ ---------------------------------- DATE...................------•--------- ••-------------- Alferations-ai d/or recommendations---------------- --------- ------------------- -------•---------------------------------------------------------....--•--•--••-•------------------...._.-------- ..-------•-------------------------------------------------------------------------------------------------•---------...--------------------------------------.-----------------------------------= ------------------------------•------------•------ =----------------------------•-----------------------------------------------------------------------•-•-• •--------------------------------•------------------- --------------- --••------•---•-•---------------------------------------------------------------------•--- 6 FINAL'•INSPECTION 8 � Date--- -•------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street ;.300 West Oak Street 144 Sycamore Street 305 West 9th Street Stockton,California Lod[,Californ a Manteca,California Tracy,California ES 9 REVISED S-59+2M15-5Z ATLAS