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FOROFFICE,USE: =6 ----------------- ------ ------------------------------- APPLICATION FOR SANITATION PERMIT Permit No. ...._.._.... _......,...,� --------- --------------------------------------- (Complete in Duplicate) Com lu P p ) 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. L{f f 2- e- -u r"71. &T- r JOB ADDRESS AND LOCATION--!!4�- 4�4 top 011,111, 7-iZ----- '-alt'7�r3'.i'(.r-----------------•---•-----------�---•-•---._........ Owner's Name--- .---004,---------------------------------------- ..-----.-. Phone....................... Address------------------------- 00�,, --•-- .......-•-------.------------------------......-----.....-•---------------..............•----••-•-•------•------------------•--..... Contractor's Name-.---- __---. ?`-c'r :S ` `� Phone................ Installation will serve: Residence 21 Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: ..... Number of bedrooms . --. Number of baths .J_.. Lot size .___' .--y«c..-........................ Water Supply: Public system E�-__Community system ❑ Private ❑ Depth to Water Table u.V ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe M -Hardpan ❑ Previous Application Made: (If yes,date-------------------- No [ "'New Construction: Yes 8"'No �FHA/VA: Yes ["o ❑ R TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) r^�� Septic T A: Distance from nearest weH�'�__Distance om foundation....P..........Material_____��------------------------------------ IV No. of compartments__...'-.Z-.-------.....:size---- Liquid depth-_-_.-.9----------------Capacity.... Dispos field: Distance from nearest weft- .--_Distance from foundation-_ R.- ..Distance to nearest lot line 3._......_..... Number of lines___________ Length of each line..... .Q Width of trench______,, _ `� Type of filter material._' __-___._Depth of filter material--/ ___________Total length........ .................. N r �.I 1 Seeps it: Distance to nearest well_-_ __Distance om foundation,c .._.______Distynce to nearest lot iine________________ n Number of pits.....__I------------Lining material__ oCit___Size: Diameter___A3.�____..........Depth------jj------.___________ r 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):-----------------------------------------------------------------------------------------=------•-------------------------------------------------------- --------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ----------------- -----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------,..--- 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 andregulat' n of the n Joaquin Local Health District. (Signed)............................................ --------------------------------------------------------------------------(Owner and/or Contractor) By:...................................... ------------------------(rtle)---------- ----------------------------------------------------- _. (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 - - -------- ---------------------------------------•---------------------------- DATE--- --------------------- REVIEWED BY------------------------------------- ---- -------------------- ---------------------------------------------------------- DATE-_------------------------------------------------------- BUILDING PERMIT ISSUED-------------------------------------------------------------- ------ DATE------------•-----------•------ Alteer�at'ons and/or rec m�,m dalions:__.______ _.._-_. .r_�_-_. - ________------------ -------__ 1 o�•� -- ► ' "'� --- --J-------I---- ��`-- -- --- -- '-'.... -- -'- - ---------- � --------------- .....------.....------------------------ ---- ----- FINAL INSPECTION BY:..-J�-- -- ------� ---------- ----------- Date _.- ... "' ..--• .............. SAN JOA LOCAL HEALTH DISTRICT 130 South American Strout 300 Wast Oak street 124 Sycamore Street 205 West 91h Strout Stockton,California Locil,California Manteca,California Tracyr California ES 9 REVISED B-59 ZM 5-451 ATLAS