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FOR OFFICE USE: ------------ ------------------------------------------- APPLICATION FOR SANITATION PERMIT Permit No. . .. `� k - (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 ereindescrbed. This application is made in compliance with County Ordinance No. 549. JOB ADDRESS AND LOCATION_ --- Owner's Name------ ^!!'1 -------i -------------------------------•- ---------- Phone...........--------•-------- Address----•------•- a � ---------- -_--_--•---------_-----_-------------_--- t_W Contractor's Name------ _ . fir -e� - - a`t:r! "'•t" Phone --'� Installation will serve: Residence i❑ Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other 'Number of living units: _____t_. Number of bedrooms ._ ' Number f baths . _____ Lot size ____-- 1} ;�....------_------------- Water Supply: Public system El Community sy em El Private [Depth TO Water Table 7w•k'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 [- New Construction: Yes ❑ No FHA/VA: Yes ❑ No TYPE OF INSTALLATION AND SPECIFICATIONS: `t (No septic tank or cesspool permitted if public sewer is available within 200 feet.) �] Distance from nearest wea_ , __E__Distance from foundation____. _ __ ___ C_t_s____",__�_.....z.......... - Se ticTank: Material No. of compartments _.-___._Size___ _ _ �{ p --x--S------Liquid depth--------�--------------Capaci+Y----��.�4_.�. t . i Dispos Field: Distance from nearest well-.-*�O--___Distance from foundation-.__1_Q..........Distance to nearest lot line._...... Number of lines-------------f__ -----___ Length of each line_.----- _ �-- ---------Width of trench------ _ � � � -- � -Z--•-----------•-----•- Type of filter material._._.4_� ,K/ --Depth of filter material------- `.._--._Total length______d../_______________________ Seepage Pit: Distance to nearest well----------------------Distance from foundation------._.__.-------.Distance to nearest lot line-.---_______.__.. ❑ 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------------------------------------------ F1 ------_-_____________------__.__.._-- -.❑ Distance to nearest lot line----------------------------------- ---------------•--------------.-..-----------------------•---------------------------------•-------------- Remodeling and/or repairing (describe):------------------------------------------------------------------------------------------------......-.----------------•------------------------------- r ---------------------------------------------------------------------------•------------------•--------------•----------•-------------------•------------•- -------------------------.....--------------------------------- - ---------------------------------------------------------------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. Si ned t' -------•---------•--40wri- and/or Contractor) By------------------ 1 ' ' i- � .: .._ {T'itle) (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). F90EPARTMEf USE ONLY APPLICATION ACCEPTED BY--------- * - DATE.. J -- --- 7X<.----------------------- REVIEWEDBY----------------------------------------------------------------------------- ------------------------------ DATE---------------------------------------------------- BUILDINGPERMIT ISSUED--------------------------- -------------------------- ---- - ---------------------•---------- DATE------------------------------------------------------------- Alterationsand/or recommendations:---------------------------------- ---------------•-----------•--------------------•------------------•----------------------------------------•-------------- -----------•---------------------•-------------------------•---•-•-•----•---------------------------- ---------------•----------------------------------------•--------------------------------------------------------------- -------------------------- ----------------------------------------------------- ----- -----------------••------------ •-- FINAL INSPECTION BY:------. . .... Date---- - ---/ ----------------------------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Srr*ot 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,California Manteca,California Tracy,California E5 9 REVISED.8.59 2M 5.62 ATLAS i