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FOR OFFICE USP: ��•-- -•-•=' APPLICATION FOR SANITATION PERMIT Permit No. / --------•-------------------------------------- -- (Complete in Duplicate] Date Issued _ -� 1 3 _---__________________________ 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 herein described. This application is made in compliance with County Or nce No. 549. 41 --------------------------------- 3 JOB ADDRESS AN CATION-------- .-- --- •----------=------------------ � Owner's Name--- - -- ----------- - ---------------------------------- ----._. Phone _., -.:. Address-----_---------------- ----•--- ....... . • ----- ---------------- --- ° Phone.�,�. ---- - •�- ----• Contractor's Name..---------- ------------------------........... Installation will serve: Residence partment House F] Commercial [3 Trailer Court ❑ Motel ❑ Other [INumber of living units: . .__ mbar of bedrooms 3-_ Number of baths _,L____ Lot size /0�.-..X-- Water Supply: Public system Community system [IPrivate ❑ Depth To Water Tabla.•�ft. Character of soil to a depth of 3 feet: Sand E] Gravel F1 Sandy Loam F] Clay Loam ElClay ❑ Adobe Hardpan ❑ \ R _-_.-1 No ❑ New Construction: Yes No)g FHA/VA: Yes ❑ No ❑ �1 - Previous Application Made: (if yes,date______________ ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) 14 c a'k: Distance from nearest well_________________Distance from foundation._._____..__-_-.---.Material-.______-._____.-._____-__----------------------. No. of compartments------------------_- :.--Size--------------•-----------------Liquid depth--------------------------Capacity..--------------------- s sal Field: Distance from nearest well-_______________Distance from foundation-------- ----------..Distance to nearest lot line___..___.........{ Number of lines---•..-----------------------------Length of each line--.-----.-------------..-----.Width of trench--------._----------- --•--- Type of filter material._--------•-------------Depth of filter material-----------------------Total length.--..---....--------•------------------.- Seepage It: Distance to nearest well t�43__r._____-Distan m undation_c �- ---.-.Distancff e to nearest lot line j�.Q.... Number of pits...-./-------------Lining material--'.Size: Diameter___��_._.....Depth__.._1J__....... ._______... Cesspool: Distance from nearest well-----------------Distance from foundation---________--_..__.Lining material-_____---_.___-----------------FIs. ❑ Size: Diameter------------------------------------•-Depth-_---------------------------- Liquid Capacity -•-g Privy: Distance from nearest well------------------------------------------------Distance from nearest building------------.---------------------- ---- -• ❑ Distance to nearest lot line--------------------------------- ---------------------------------------------- , Remodeling and/or repairing (describe):-------------------------- -- -•------•-- ----------------------------•-•----•----------------------•---- -- ---------------------- ----------- ------------------------•-----•--------------------•-------------••------------------------------------------------•----------•---- I Hereby cert" at I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, Sta law , and rules and re ations of the San Joaquin Local Health District. -------------- --- ---- -------- - --- ner and/or Contract w d/o ori {Signed} - --- - Tale . By:--------------------------------------------------------- --------• f (Plot plan, showing size of lot, location of system in relation o wells, b ' Ings, etc., can be p1l.ace&bn reverse side). FOR DEPARTMENT USE ONLY APPLICATIONACCEPTED �--.-- - -----------------------------------------------•---------------- DATE---3-- 'r1_- --------•----------------- REVIEWEDBY----------------- -------... DATE---•--------------------------------••------------ BUILDING PERMIT ISSUED-------------------------------- -----------•- ------ DATE--------------------------------------------- ------------------------------------ Aiterations and/ omat-ons: ------------ -- 1 _ : ..: r . ' ---- ---------------------------------------- ------------- ------- •------- -------------••- ----------------------------------------------- ---------------------- ---------••-----------•------------------ -. --------- .-_--•-----------------------•------------------------------------------------ ----- •---------------•------------ --------------------------------------- --- -------------- P� t FINAL INSPECTION BY:.----- -- -- ---- Date---- -_--------•---------- --•------ 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 ES 9 REVISED a-59 2M 5-62 ATLAS