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OR OFFICE USE: � . --_ -__._ ---.--__.-.__ __._-- .- ------------- APPLICATION FOR SANITATION PERMIT Permit No. ...........:.. .t . ------------- -------- -) ----------- (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 herein described. This application is made in compliance with County Ordinance No. 549. r S JOB ADDRESS AND LOCATION---- --7�' 4) .- ------------------ I L / Owner's Name_- 4 ?- ------------------------------------- Phone.:--T Address--------- Contractor's Name --- -----------------------------------------------------------------------------------------•------------------------ Phone................................... Installation will serve: Residence [}. Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: ---/--- Number of bedrooms --_2--Number of baths J___ Lot size ..../ ...___x.__._L_ .I-__---• Water Supply: Public system N Community system ❑ Private ❑ Depth To Water Table -------- ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe k Hardpan ❑ Previous Application Made: (If yes,date--------------------) No ❑ New Construction: Yes ❑ No [10 FHA/VA: Yes ❑ No IR TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tank: D' tante from nearest well------ ------Distance f om foundation....................Material.... - _..... `� ( � 0. of compartments.-._---_-- __-.____Size____--- -----_:_-•Liquid depth--------------------------Capacity..,.CTG.. �t-�f C � f Isposal Id: Distance from nearest well------" Distance from foundation...©.___.......Distance to nearest lot line....... ....... Number of lines______________, Length of each line----------- _C_.___ Width of trench----- ____--_-_---__-_____..__ ,� Type of filter material4C`-------------------Depth of filter material_-_-__�__ ___------Total length_._.....��r..___..._.__.__...._.____ r Seepage Pit: Distance to nearest well------- ----------Distance from foudation..._1.G 1._..___.Distance to nearest lot line...s......... 1 Number of pits------.__(------------Lining material__ .. Size: Diameter_.Z._.ltat.__..Depth_..�......-fir...................... Cesspool: Distance from nearest well-----------------Distance from foundation---------------.---.Lining material------.____-__-____.-______-___-_-_-_ ❑ Size: Diameter--------------------------- ---------Depth----------------------------------------------------Liquid Capacity_-------------------------gals. 0 Privy: Distance from nearest well------------------------------------------__-__Distance from nearest buildingr ❑ Distance to nearest lot line------------------------------------------------------------------------------------------------------------------------------------------------------•------- ----------------------------------------- Remodeling d/or repairin 0):------ ----------------- ----- ---------1._--_.____---- --_-- ------------t>CJs --------------- ........---------------------------------------------------------------------------------------------------------------------------------------------------- -----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------•----------------------------------- I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State41aws, rules a d regula�ns 9f the San Joaquin Local Health District. (Signed)•--------- 7 ----- rw red or Contractor) By:--------------------------------------------------------- -------------------------------------------------------------------------(riifle)--------------------------------------------- ---- --------- (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). FO DEPART NT USE ONLY APPLICATION ACCEPTED BY------- ,el........ --- ---- - - ----------------------------------------------- DATE-----.'12..--.Z-- -------_- REVIEWEDBY------------------------------------------- ------------------------------------------------------------------------------- DATE........................................................... BUILDINGPERMIT ISSUED----------------------------------------------------------------------------------------------------- DATE------------------------------------------------------------ Alterationsand/or recommendations------------------ ----------------------------- -------------------------------------------------•------------------------------------------------------------- --------------------------------------------------------------------------- ---------------------------- ----------------------•--•--------•-------- ----------•----------------------------------------------------------- -------------------•----------------------------------------------------- ------------------------------------- -----_------------------------------------------------------------------------------------------------- ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------- ------------- -------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------ FINAL INSPECTION BY:.-C.......?1304-S--------------------------------- Date----4 ' !- O ------------- ----------------------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Strout 300 West Oak Strout 124 Sycamore Street 205 West 9th Strout Stockton,California Lodi,California Manteca,California Tracy,California ES 9 REVISED a-59 2M 5-62 ATLAS