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- rVKUrrICt U ..... APPLICATION FOR SANITATION PERMIT Permit No. ....... (Complete in Duplicate) ----------------- ------------------ =----==----------.� This Permit Expires 1 Year From Date Issued Date Issued ... .1 - Application is hereby made to the San Joaquin Local A + re District for a permit to construct and install the work herein described. This application is made in compliance with County r once No. 549. , ,rte J013 ADDRESS AND LOC ON � .. .. M ----------------------------------_-----_...... Owner's Name---- ...... --------------------------------------------------------------- Phone.................................... Address �t -!�..�-- - -------------- •----------- -------•--------------------•-----------------------••-_----•----------------•-----•---•--------------------- --------- Contractor's Name ��. ._` _.. --- ---- Phone..- ------• 4 Installation will serve: Residence [+i}partment House ❑ Commercial ❑ Trailer Court ❑ Motel [I Other ❑ Number of living units: ..___ Number of bedrooms._. Number of baths __/_ Lot size .. ,/ ^ ... Water Supply: Public system E] Community system E] Private�Depth to Water Table -1^4ft. l 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 ❑ New Construction: Yes ❑ No �HA/VA: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: - a (No septic tank or cesspool permitted if public sewer is available within 204 feet.) S is T Ir-- Distance from nearest well_________________Distance from foundation_______......______.Material ___.__.______.__.._.._..........._..........:.... No. of compartments--------------------r-Size.......... ------------- Liquid depth------------------------ Capacity................... osal i Distance from neare t well ' __:Distance to nearest J_ iine__.Qv1_" �i�_____.._.Distance from foundation._ _ \ -�`�'1 Number of lines__..._____ -.Length of each line------ ------. Width of trench... fJ �. �� Type of filter materia -_-Depth of filter material--f /------Total length______________________ a i Distance to nearest well_- -- Distance from foundation__ .... � � ce to nearest lot line__. ----- Number of pits._._______________Lining material_ 0- -------Size: Diameter_ 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 I Remodeling and/or repairing (describe)____________________________--________.____.---...________---____ ---------------------•-------------••-----••--------.----••----...-----------------•-----------•--•-•-----------------------------•----•-----------------------------------•-----•--•-•-•--•-_---------------------------- I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, Stat s, and rules and regulations of the San Joaquin Local Health District. (Signed)_ By-------- - - 1 Contractor)or --------------------•------.------------------- -------------------------- A- (Ttle)------------------ ----- ------------------- (Plot plan, showing size of lot, location of system in relation wells, buildin etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY-----Q__.-.- r� --- -------------------------------------------------------------- DATE_...�__'.1-�-=--..h_ -----•-------------------- REVIEWEDBY---------------------------=.................-----------------------------------------------------------------------------.. DATE BUILDINGPERMIT ISSUED-----------------------------------------------------------s- --------------------------------- DATE------------------------------ Alterations end/or recommendations:--- -.-'-l-S-- - ,-----------� _...ln , _ ln-•.------ -s�e � ------ -------- ....-•-----------------•--•---------------- > -------------------------- ------------------------••--------------------------- -----••------------------------••-------------------------------------- FINAL INSPECTION BY:----C,---- s±, --------------- Date.-_ .- -�- t SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,California Manteca,California Tracy,California rG 9 REVISED 8-99 2M 5-61 ATLAS