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FOR OFRC USE y --- ----------_�,------------------------------_--_---. APPLICATION FOR SANITATION PERMIT Permit No. - --- ------------------ l q� . . -- ------------------ (Complete in Duplicate) �!'. ,� �� I .--_..-..- l /-- -v____________________ This Permit Expires 1 Year From Date Issued `� Date Issued ________J_ ;..� Application is hereby made to the San Joaquin Local Health District fora permit to construct and install the work herein described. This application is made in compliance with County Ordinance N . 549. JOB ADDRESS A D LO ATIO - ----------- -- ---1 . .....-.- �4ZL_/ Owner's Name-------------- Phone_ b3 - ___ Address } ---- -------- - -------------------------- ----------- ---------------••---- •-•••••---- - 1CContractor's Name...--. � - Phone- Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: ----I--- Number of bedrooms:.2 -. Number of baths /___---- Lot size __w_p x�7a....................... -------------- Water Supply: Public system Community system ❑ Private ❑ Depth TO Water Table Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe n—'Aardpan ❑ Previous Application Made: (If yes,date--------------------) No ga-� New Construction: Yes Er'�No ❑ FHA/VA: Yes ❑ No TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) SepticTP, ank. Distance from nearest weil-----------------Distance from foundation-------------------Material---------------.-------.------------------------. d ' No. of compartments--------------------------Size--------------------------------Liquid depth-..-----------------------CaPacity---------- ............ Disp a1 Fid Distance from nearest well-----------------Distance from foundation---- :---.....Distance to nearest lot line................. Number of lines-----------------------------------Length of each line....._------------------------Width of french-------------------------.......... Type of filter material-------------------------Depth of filter material----:------------------Total length------------------------------------------ SeepaPit: Distance to nearest well--- Distance-ftQm foundation-�----------.-..Distance to nearest lot line----------------- [' Number of pits--------_--_ ------Lining material----1-_--.G- '-----..Size: Diameter------33 4--- .----Depth-------.-23=`_---------_ Cesspool: Distance from nearest well_- -------- ....Distance from founda+ion--------------------Lining material----.-..---------_-------_.-_-.---- E❑ Size: Diameter-------- ----------- -----------------Depth----------------------------------------------------Liquid Capacity----------------------------gals. Privy: Distance from nearest well-------------------------------------.--: ------Distance from nearest building--------_---.--.___..------_-.------------ - ❑ Distance to nearest lot line------------------------------------------------.... . --••---•------------------------------•-----..-•--•----•------------•-------------- Remodelingand/or repairing (describe)--------------------------I-------------_----------------......--------------------•-•---------•--........---------------------•-------------------------- -------------------------------------------------------------------- ----------------------------------------------------- -----------------------------------------------------------------------•--------------------•-------------------------------------------------------------------------- --- - ---------------------------------•------------------•----------------------•------------------•-----------------------------------------......----------------------------------------------------------•---.---•--- hereby certify that I have prepared th isand +ha the work will be done in accordance with San Joaquin County ordinances, State laws, and rules and regulan Joa uin Local Health District. (Signed)----------------•-------_............-_.-----••-- -------•- ------- -----------------------------------------------------------------...(Owner and/or Contractor). �y By:. ---------=------ ------------------------(Title)-----------•-----•----------------------------------------- - - - -------- (Plot plan, showing size of lot, location o system to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY------------------------------------------------------------------------ - f� --- DATE-------- '- REVIEWEDBY------------------------•------------------- ---------------------------------------•-------•---------------------------..._ DATE BUILDINGPERMIT ISSUED-------------------------------------------------------------- ----------------------------------- DATE_—---------------------------L--------------------------- Alterations ATE.-—-•-------•--------------------------------------------- Alterations and/or recommendations:-------------------------------------------------------------------------------------..------------------------------------------------------------------------ -------------------------------------------------------- -------------------------------------------------------•--------------------------------------------------------------------------------------------------------------------------------------------------------------------- -------------------------------- k- ------ -- ------------- ------------------•---------------------------- ----------------------------------------------------- FINAL INSPECTION BY:---- ---S' QUIN --------• --------------- Date----- ---1-------------------------------------------------------- ------ SAN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,California Manteca,California Tracy,California. ES 9 REVISED a-59 2M 5-62 ATLAS