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FOR OFFICE US : -� 7 _________________ -------___--------------_------------ APPLICATION FOR SANITATION PERF"111 Permit No: 4, --------------------------------------------------------- (Complete in Duplicate) r d t i ---------------------------------------------------------- This Permit Ex fres 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. JOB ADDRESS AND LOCATI N-..`__ �2 ------------- ---- --------------------------------- -•---•------.----------------------------.-.----------------------....... Owner's Name___---•--�^=_---- •-•----1'/---- t l------ ----------------------------------------- •------ Phone------------------------------------ Address ��. .._ .:. -- - - ' *---- ------------------------•---•-..._•-_...•••••••----------------------------...••-----••••--................................................. Contractor's Name ----•- --------------------- -•-------------------------------------------•--------••---------- Phone.........------------------...... Installation will serve: Residence ❑ Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other 0— Number of living units: ____... Number of bedrooms -------- Number of baths ...._-_- Lot size ____________________________________________________________ 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 0—Aardpan ❑ Previous Application Made: (if yes,date--------------------) No [ Now Construction: Yes E"o ❑ FHA/VA: Yes ❑ No Co-- TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septi Ta k: Distance from nearest well_________________Distance from foundation____...____________.Material................................................. No. of compartm�nts-----------•--------------Size--------------------------_-----Liquid depth--------------------------Capacity---....•-•--.......:.. Disp aL F� Id: 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.......................................... 5eepa Pit: Distance +aPearest�well--- ��,__ ____Distance am f Distanceundation___:7��r_____. to nearest lot line��_�__ Number of its______________________Lining material ___-Size: Diameter__._- ---------Depth____. Cesspool: Distance from nearest well-------_---------Distance from foundation--------------------Lining material------------------------------------- El Size: Diameter---------------------- I ----------------Depth----•------------------•- •- ----------------------Liquid Capacity-- •---....-•--------------gals. Privy: Distance from nearest well_----------------------------------------------Distance from nearest building----------- _--._______________________- ❑ Distance to nearest lot line---------- ----------------------------------�----•--/----------------- Remodeling and/or repairing (descrL):_--- ...7_ - -!-------o!�'v`"____�#� : . --------••--------•--------•-----------------------•-------------------------------------------....---------•----------------------------------------------- -----------------------------------------I I hereby certify that I have prepare hi application and that the work will be done in accordance with San Joaquin County ordinances, State laws, and rules and r I ons of the San Joaquin Local Health District. (Signed)-•-•••--•.......................... (Owner and/or Contractor) By: •- ------------------------------------------•-------------------------------------------(Title)----------- -----•-------------------------- -- --- ------ (Piot 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----- I REVIEWEDBY-----------------•-------------------•- -------------------- ----------- ------------------------------------------------ DATE-------- BUILDING PERMIT ISSUED----------------------------------------------------------------------------------------------------- DATE---------_ Alterationsand/or recommendations:--`.---------------------------------------------------------------------------------------------------••---_---•-•--------••-•---••----••-•-------•--•-•------- t __-•-----------------•-•-------•----------------•__--••••------ -•--•-•---•--------•------------------------............••-----------------------------------------_-................................ ------------------•-------------------------------------------- -----------------------------------------------------------.......................................................................... i r FINAL INSPECTION BY:---- -' a Date_.. k (0 (0-1'------------------------ SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street- J 300 West Oak Street 124 Sycamore Street 205 West 9th Street -• r Stockton,California Lodi,California Manteca,California Tracy,California ES 9 REVISEO 6.89 VM 5-61.ATLAS