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FOR OFFICE USE: ------------- _____________ _ __ _ _ _ .............. APPLICATION FOR SANITATION PERMIT Permit No. ... ....... ................... lam ` ---- (Complete in Duplicate( 7� f Date Issued _. -------------------- This Permit Expires 1 Year From Date Issued ... ..`.7, , Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the rkTi-erein described. This application is made in compliance with County Ordinance No. 549. E JOBADDRESS�AN ATI h � t ,n. r Owner's Name ............. -• •..................... •••.... Phone. -------- .................... Address. t. _. l .. -----.-- - --- --•- ...:..... Contractors Name..... Phone.................:................. Installation will serve: Residence A Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: ._. _. Number of bedrooms . Flumber of baths :__ . Lot size Lp .......................... Water Supply: Public system ❑ Community system ❑ Private 0 Depth to Water Table ........ ft. Character of sail to a depth of 3 feet: Send Q Gravel ❑ Sandy Loam ❑ Clay Loam Clay❑ Adobe❑ Hardpan Previous Application Made: (If yes,dote____________________) No ❑ New Construction: Yes ❑ No ❑ 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: Distance from nearest well.................Distance from foundation....................Material................................................. ❑ No. of compartments..__............................Size................................Liquid depth..........................Capacity... ...... ✓ Disposal ' d: Distance from nearest well 5'O.....Distance from foundation U../..._.Distance to nearest lot line... C1 Number of lines_.__.._.,.I_ --•--.-. ......Length of each line.........��___._.........Width of trench.......X! ............._... Type of filter material...•--..Depth of filter material....... -I.. ......Total length.........4:0../.................... Seepage Pit: Distance to nearest well......................Distance from foundation....................Distance to nearest lot line................. ❑ Number of pits.... ..........Lining material.......................Size: Diameter.................................Depth .............................. I Cesspool: Distance from nearest well Distance from foundation....................Lining material..._ ....... r ❑ Size: Diameter...... --••-----` ---•--------•--..Depth-----------------------------------------._.-_•_....Liquid Capacity ......... ..........gals. Privy: Distance from nearest well.................................................Distance from nearest building.......................................... ❑ Distance to nearest lot line...................................................-......._.. -----------------•-----•----• I...... ............................. � /or.repairintl —sc e):....•-•----------------•-•--......--••--.... ......•. ------.............-. ......... ......... .....:.._ ......... ...... --•----•-••--------•---•-------•----•------------•--......--••----------------------------------------------------•--------•--•------------.......-•--•----------••----------•-•--------...................................... 1 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. (Signed) ......:.... •--••...••-- (Owner and/or Contractor) By: (Plot plan, showing size of lot, location of �� tem in relation to wens, buildings, etc., can be placed on reverse side{. FOR DEPARTMENT USE ONLY APPLICATION-..ACCEPTED BY.: _.. •-- .................................-..................... DATE--f.- .... /�- REVIEWEDBY....................................••........................................................................................ DATE........................................................... BUILDINGPERMIT ISSUED.....................•------•-•------------•---•--••-----•---- ...................................... DATE............................................................ Alterationsand/or recommendations:............................................_t_........................................... ..........-•••--•-----....--•-.....•--•----•--•---..........•---- -•••--........•••-•-----•- .......----••••.....•--•--.....•-••.....•••.....--•---••-•----•••-•............... ?. .................................................................................................... 1 FINAL INSPECTION BY:.. ------------------------ Date.... ._= -.4�1 ---------------- •--•--. . ---•---•---•--•. SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak street 134 Sycamore Street 405 West 9th Stroot Stockton,California Lodi,California Manteca,California Tracy,California 'ED 9 REVISED 6.59 !M 6.61 ATLAS