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FOR OFFICE UISE: _.._________________V.--_.__..__..__-_____.____.-___ APPLICATION FOR SANITATION PERMIT Permit No. ......... ----------------------------------------------------- (Complefe in Duplicate) 11 ------------------------------ ---- ---------------------- This Permit Expires I I 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 0 dina a No. 549. JOBADDRESS AND V�ATION....... -------------_--------------------------------------------------------------- Owner's Name............. ---------------------------------I--------------------------- Phone------------------------------------ Address-----------_- -- -- - --- ------------- ....... ------------------------------------- .... ...... -------------------------------------------------------------------------- Contractor's Name.............................. ---- --- ----------------------------------- i --- ---------------------- Phone..............I.................... Installation will serve: Residence @---Apartment House E] Commercial E] Trailer Court El Motel 0 Other El Number of living units: /---- Number of bedrooms c;2-. Number of baths __/_ Lot size ..........I.............. Water Supply: Public system [Community system 0 Private E] Depth to Water Table Y4`ff. Character of soil to a depth of 3 feet: Sand E] Gravel 0 Sandy Loam El Clay "m E] -Clay [] Adobe 03---Hardpan I-] Previous Application Made: (If yes,date---------------_---) No E] New Construction: Yes El No 9?-'_FHA/VA: Yes 0 Noo TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted,if public sewer is available wifhin. 200 feet.) it Distance from nearest well.________________Distance from foundation........-----------Material.................................................os No. of compartments--------------------------Size--------------------------------Liquid depth--------------------------Capacity.,..................... CIS R Distance from nearest well----------------Disfance from'founda-1 ion.-.-.-----------Digfi"nfo--ce nearest lot line................. os of lines-----------------------------------Length of each line---------------------_------Width of trench_-;-----------,.-_-.-.-------------2 Type of i fi.Iter material-------------------------Depth of filter material---_-___-__------------Total length---------I ------------ e ge Distance to nearest well"--K-V---Distancundation__/&.'.__.-Distance to nearest lot Number of pits-------/-----------Lining material Size: Diameter-----133: Depf h21.R.-z."--------------- Cesspool: Distance from nearest well_________________Distance from foundation- - ---------------Lining material_t.....;.............. ------------- El Size. Diameter--------------------------------------Depth----------------------------------------------------Liquid Capacify-...........................gals. Privy: Dis,fance from nearest well-------------------------------------------------Disfance from nearest building_______________________-______.__.___..__. ❑ uilding------------------------------------------ F1 Distance to nearest lot line Remodeling and/or repairing (describe):------------------------------------------------------------------------------------------------_................................................... ------------------------------ --------------------------------------------------------------------------------------------------------------------------------------------I--------1--------------------------- ---------- --------------------------------------------------------..................----------•----•--•----••-•-----------•---••i--------------------------••-•----•--•--•---------------•----------------- .............................................................. -----------------------------I---------------------------------------------- ............*-----------------------------*--------- ------------------ I hereb certify that I have prepared this application and fkat the work will be done in accordance with San Joaquin County ordinances ate laws, and and regulations of the San Joaquin Local Health District. JJ (Signed).... •. ... %------ ---------------- and/or Contractor) BY:............................................... .................... ------------------ ------------------------ (Plot plan, showing size of lot, location of system in relation to wells, gs, etc., can be placed on reverse.side). FOR DEPARTMENYUSE ONLY ----------- APPLICATION ACCEPTED BY---- ---- ----------------- - ------------- ------ REVIEWED BY------ --------- ------------------------- ------------------------------------------- --- -------- DATE------------------------------------------------------------ BUILDINGPERMIT ISSUED------------------------------------------------------------------------------------__------------- DATE--------------------------------- Alterations and/or reqorngnari�dafions:---- ----------------------- i--- -------------_- --- ------------------------/_ - -- ------- -------------------------------------------- ------------------------------------------------------------------------------------------- -------------------------------------------------------------------------------I------••-_------• --1--------------- ................................... ------------ --------------------------------------------------------------------------------------- -------------------------------------------------------- ------------------------------------------ -- FINALINSPECTION BY:----------- --------- --*- -------------------------------**------------***"*------------------*----------------------------------------------------------------------- --....-------- .... . .. -------------- Date-- ------------------------------ SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South Amirican Street 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,California Manteca,California Tracy,California KS 9 REVISED 6-99 2M 5-61 ATLAS