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FOROFFICE USE Cho �t L 3 C - -------------------------------------------------------- APPLICATION FOR SANITATION PERMIT Permit No. . -_••--7-•-----.. -------------------------- ------------------------------ (Complete in Duplicate) ---..----------------------------------------------------- This Permit Expires 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. ..�✓ 1 � �'u-fr JOB ADDRESS A LOC TION ---•--2 ��' ' G'I L - p --P'f.� 11 A'i fr 'i ... r��'-J � Owner's Name_ •••i---••---- . ----••--------- ----••----••---._. Phone------------------------ Contractor's Name___________ __________ Phone-.................................. Installation will serve: Residence Apartment Ouse ❑,, // Commercial 0, Trailer Court E] Motel E] Other ❑ Number of living units- __ __ Number of bedrooms `k Number o baths ___/__ Lot size ..._- ______________ 1 Water Supply: Public system ❑ Community system ElPrivate Depth To ater Table Sfl ft. Character of soil to a depth of 3 feet: Send ❑ Gravel ❑ Sandy Loam Clay Loam ❑ Clay ❑ Adobe❑ Hardpan ❑ Previous Application Made: (If yes,date--------------------) No f] New Construction: Yes,N 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 depth---------------- -------- Capacity-------------------_- Dispos ield: Distance from nearest well----Sd __Distance from foundation__�____�____Distance to nearest lot line_ ...... Number of lines---------- -----------------------Length of each line.....__.1___----. Width oftrench.---�--------r---______------ Type of filter material_ /4nk.Depth of filter material----j,�?-----------Total length........ __a_._Cj_____________________ Seepage Pit: Distance to nearest well----------------------Distance from foundation.............._-__.Distance to nearest lot line.............. ❑ Number of pits------------ -----Lining material-----------------------Size: Diameter-----------------------Dept h................................. 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.-----------••----------------------------------------------------------•--------------------------------------------------------------------- Remodeling and/or repairing (describe):--------------------------------------------------------------------------------------------•-- ----•------•-----------------•-•-••--------•-----.. ------------------------------------------•-----------------•-----------------------------------------------------•-------•-•---•---......._.. ••-••---••---------------.. --------•---•-------.................. ......... 1 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State la red rules end req lations of the San Joaquin Local cal+h District. (Signed)------------------ •--•_. . . . fOwnp� ,.�.�/.,. Contractor] By: - --------... (Title) -------------------- -------------- (Plot plan, showing size of lot, location of system in relation to wells, build s, etc-, placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY--------------------------------------------------------- ----------- ��- - ----- DATE-------- - r ------- REVIEWEDBY.........----------------------- ----- -- - --------------- DATE----------------------------------------------------------- BUILDING PERMIT ISSUED----------------------------------------------------------------------------------------------------- DATE_------•-------------_--- -----------------_---•---•- Alterations and/or recommendations----------------------------------------- ------ --__................................-------•--•----------------------------•-•---•-•----------------------- -------------------------------------------------------••--------------------------------------- ----------------------------------------------------•-------------------------------•------------------------------------- ------------------•-•-----•-•-•-•-------•••------------•-••----- -•---------------------• --•••--•--•--- ------•-----••--------------------•---•---•-•-•--••-------_----------------•-------------•----------------------•-- ------------•---------------------- --------------------- •--------------------------------------------------------------------•-----------------•-•------------------------------------------------------------------------- FINAL INSPECTION BY:... ---- l - ------------------------- Date_....I/ .: to --------------------------------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 124 Sycamore Street 205 Weil 9th Street Stockton,California Lodi,California Manteca,California Tracy,California ES 9 REVISED 8-59 2M 5-62 ATLAS l h - -