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FOR OFFICE USE: ..._----------------------------a:.4.--------------------- -------------------- APPLICATION FOR SANITATION PERMIT ( Permit No. ...�<a�..., . ---- (Complete in Duplicate) ....� ---------------------- �--- -------------.--- This Permit Expires 1 Year From Date Issued Date Issued ... ../...�. Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work heroin described. This application is made in compliance with County Ordinance No. 549. JOB ADDRESS AND LO ATION.._L ,a!� � __..._.G` � ''` ...._ :`°:......... ....�:: ..........;,........: Owner's Name 4/1' ---------•---- ----- ---------------------------------------- Phone.................................... Address................ �" -+'� �! Contractor's Name.--..../- c..-•---•-•----••---------------------------------------------------------------------------•------------------ Phone................................... Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: ---t--- Number of bedrooms -3... Number of baths I--.- Lot size J"--j'..f r:o............................... Water Supply: Public system ❑ Community system [I Private a] Depth to Water Table f7nSft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam Clay Loam ❑ Clay ❑ Adobe❑ Hardpan ❑ Previous Application Made: (If yes,dote--------------------) No (9 New Construction: Yes 0 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.:-�Q.......Distance fro foundation__1_ . ----_.Material-• � .....6, ........ No. of compartments----.2...................Size_rar ..:_..Liquid depth..... -__---------------Capacity../.,,2-.4V....... Disposal Field: Distance from nearest well_./.-4�7�-----Distance from foundationll......_....Distance to nearest lot line... ...... JT Number of lines......t _ _________ ____ _Length of each line.... O. Width of trench....Ll/.�.._.._......_..... Type of filter materia 1-oro-If _Depth of filter material--1. --1.9 length.__, m........................... 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......................................._. ❑ Distance to nearest lot line-------------------------------------------------------------------------------------------------- .......................................... y► Remodeling and/or repairing (describe):......................................................................................................................................................... ------------••---•-----•-----•---------------------•-------•------•----•-------- ------------------------•---------------•----------------------------•--...----------------•---...._.......---------.......--•••-•----- ------- --------------••-----------•-----------•-------------••---•--•------------------•----------•--•---------------•--------------••--•--•-------------------•-----------•-•---------------•--------•......_...----------- ......----••------------------------------•---•-------•----•---------------•-----------•--•-------------•----------•--------------------------•------------------••--•------------•--•••-------------------------------------- 1 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State , and rules and regulations of the San Joaquin Local Health District. (Signed).. -----------(Owner and/or Contractor) By• Title_ . --•-•-----•--•••.._.....••--------------------•----------•-----•--------------------------------------------- ( )•-----------------.------------- ------ f (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....1.�P.-... .......................... REVIEWEDBY.............................................................................................................................. DATE............................................................ BUILDINGPERMIT ISSUED..............................................................-...................................... DATE............................................................. Alterations and/or recommendations:............................................................................................................................................................... -----------------------•---•-•---------------------•-----•--------••---.....----------------------------------------------------------------.....---•-----------..._...-•----------••--------------..............---------••- --------------------------------------------------•------•-----------------------------------------------------------------------------------------•-•------•-----•-------••-------------------------------•----•-•-•--•••. •----•----•----------------•-----•-•-----------------....--•-------------------------------------------•-----------------------------------------•----------------------•----••---•-•-•--...------------------------------... ---------------------------------------------- ----------------- ------- ------------------•--------------------------------------•-----------•----------...---------------------•--•----------------------•-•-----•---- FINAL INSPECTION BY:. = ----------- Date../0).-:} -----------------• SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Strout 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,California Manteca,California Tracy,California E8 9 REVISED 8-59 eM 5.61 ATLAS