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FORUFFlU USt: a APPLICATION FOR SANITATION PERMIT Permit No. --------------------------------------------------------- ............. _----- - {Complete in Duplicate) Date issued -------------------_---_________--------------_----------- This Permit Expires 1 Year From Date Issued Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work hefein described. This application is made in compliance with County Ordinance No. 549. JOS ADDRESS AND OCATION--- j� _______________�Z'_---- J A _ .................... Owner's Name Phone Address----- . Y:ry - 7� �� . '--- --------------- -•-•-----------------------•------- -. �Contractor's Namer,��.c-f'—✓ '�4-.�._ c_.-.... --1 �' -� -.....----•--•-------------------- Phone................................... Installation will serve: Residence 0 Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: A---- Number of bedrooms Number of baths _1--- 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 a Clay Loam ❑ Clay ❑ Adobe❑ Hardpan ❑ Previous Application Made: (If yes,date____________________1 No ❑ New Construction: Yes ❑ No ❑ FHA/VA: Yes ❑ No ❑\ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tank: Distance from nearest well_________________Distance from foundation--------------------Material _______________.•....._._.._._.._............... ❑ No. of compartments--------------------------Size--------------------------------Liquid dei?h--------------------------Capacity..................... Disposa ield: Distance from nearest well...._SQ_.._Distnnce from foundation____..1. .......Distance-to nearest lot line-_�--------- Number of lines-------------- ____________ -- Length of each line-------- -'_.______If__ Width of trench___.__- Type of filter material...._ ____Depth of filter material________)1_--.----_Total length•_...•.•&q__________________________ Seepage Pit: Distance to nearest well______----------------Distance from foundation--------------------Distance to nearest lot line............----- ❑ Number of pits----------------------Lining material-----------------------Size: Diameter........................Depth....................------------- Cesspool: Distance from nearest well-----------------Distance from foundation____________________Lining material..................................... ❑ Size: Diameter_.-------- ----------------------•--Depth------------•-------- ------------------------------Liquid Capacity--••-.....------ ----------gals. (� Privy: Distance from nearest well-------------------------------------------------Distance from nearest building________________....._---_......-.___. ❑ Distance to nearest lot line---------------------------------------------------------------------------------------------------------------..................... `` Re -i —and/or a �or repairing (describe)-------------- rC � ---------_-- .........................-------------------------------------------------------------------------------------------------------------------------------------- .-----•--------•---------------------------------------------------------------------------------------------- ......:.-•----.-_---•------•--------- I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, Stat aws, and rules and regulations of the San Joaquin Local Health District. \ (Signed)--------------- --------- u - ------.... --------------------------------------------end/or Contractor) By ..... : -�''�„'�-------=-----'"------------------•------------------------------------•-.---------------------•----(rtle)---------------------------------------------- -- .x (Plot 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 2 -��Y--- - ------------------------- REVIEWED BY-----------------------------------------------------------------------------------.-------------------------•--------_..--• DATE-------••------•--•---- ..•-----------•-------------------- BUILDINGPERMIT ISSUED---------------------------------- -------------------------------------------------------•---- _.-- DATE------------------------------------------------------------- Alterationsand/or recommendations:---------------------------------------------------------------------------------------........-------------------------------------------------------------... -_----•..---••------------------------ ------ ...............---------- -----------------------------------------...........-----------------------------------------------••-------------------------------------------- --------------------------------- FINAL INSPECTION BY:--- .- -- - - - ................... Date.... ......... --------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 124 Sycamore Street 205 West 91h Street Stockton,California Lodi,California Manteca,California Tracy,California ES 9 REVISED 5-69 2M 5-61 ATLAS