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FOR OFFI E USE: � N -, --- - ------------ ------------- -- APPLICATION FOR SANITATION PERMIT Permit No.:....... 1 .1.� ------------------------- ----I-------------------------- (Complete in Duplicate) Date`issued ---- Application is hereby made to the San Joaquin eLocal Health t Expires i Year From Date Issued l District for apermit to construct and install the work,herein described. 1 This application is made in compliance with County Ordinance No. 549. JOB ADDRESS AND LOCATI N._-..! !`-:`_4� �Y -- - - -- -- - - - Owner's Name--a. ------- ----- -------------- ------------------- --------------------------------------------------- Phone.................................. Address----___v ---- Contractor's Name_____________� k� 43 Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: ._____ Number of bedrooms ._& Number of baths ._j---- Lot size .--- x.. .. . ............................. Water Supply: Public system [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 Hardpan ❑ Previous Application Made: (If yes,date--------------------) No W New Construction: Yes eNo ❑ FHA/VA: Yes ® No TYPE OF INSTALLATION AND SPECIFICATIONS: . (No septic tank or cesspool permitted if public sewer is available within 200 feet.)i �,, Septic nk: Distance from nearest weh%p-7�---Distance from foundation__/O----.------Material______ !• . - No. of compartments---------I--_____..___-Size------3_X_C:k--- _-_Liquid depth___.y--- ---------------Capacity.... 5?. Disposal Field: Distance from nearest well_.— ._____Distance from foundation.14t_ .. Distance to nearest lot yine___`5........ Number of lines_______ZLength of each line--4.!? _. -_.Width of trench._o4_________________________ Type of filter materia_____ __________ Depth of filter material----/$_rT __----.- otal length._..:.? -------.________-_---/.____ Seepage -t: Distance to nearest ell--------`—___-.Distance f ndation__ ............Distance to nearest lot line-_ ( Number of pits_________ ___________Lining materia_____I (.l. ___size: Diameter__...33.__._ Depth Cesspool: Distance from nearest well-----------------Distance from foundation---.----------------Lining material..4--- -------------------------_-- 0 Size: Diameter--------------------------------------Depth----------------------------------------------------Liquid Capacity----------------------------gals. Privy: Distance from nearest well-------------------------------------------------Distance from nearest building-----___-_--______-__-__._._.----..___.._. ❑ Distance to nearest lot line--------------------- --•--------•_---------- ------------------------------ Remodelingand/or repairing (describe) --------------------------------------------------------------------------------------------------••-------------------------....--•--------•----•-- ---•-•----------------------------------------------•----------------•-------------------...--------••----------------------•---------------------------- •---------------------------•------•------------------------------- -------•-•-----------------------------------------------------•--------------------------------------------------------------------------------------------- --------------j'. ------•------- -----------------------------------------------•------------------•------------------------------------------------•-••----------••-•------------------------------ I hereby cet I h v preps ed this application and that the work will be done in accordance with San Joaquin County ordinances, Statnd I s and egulations of the San Joaquin Local Health District. ___-_.Owner and or Contractor(Signed)-•----------- ---- - - - { / �By.•-••-•---- -- ----- --- ----------------...------------------------------------------------------------------------(Title)---------------------------- -- -------- --------- (Plot plan, show , location of system in relation to wells, buildings, etc., can be placed on reverse side). { OR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY ----- - - ------------------------------ -•---------------- DATE------------- z — ------------ REVIEWEDBY------------------------------- - - ---- -- - - --- ------------------------------------------------------•-----------•--- DATE---- -----------------•------------------------------------- BUILDINGPERMIT ISSUED----- ----------------------_-------------------------------------------------------------------• DATE------------------------------------------------------------- Alterations and/or recommendations:-.------------------------------------------------------------------------------------------------------------------------------------------------------------- ---- ------------------ FINAL INSPECTION BY:. - ------------ - ----- --- Date-------- � " . ... _. _ . SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Srreet 124 Sycamore Street 205 West 91h Street Stockton,California Lodi,California Manteca,California Tracy,California E5 9 REVISED a-59 EM 5-62 ATLAS