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1-UK UNILt US!:: ---------------- ----------- -------- ----------- --- -- w--t ---�#- -�a�-cam y�---1_,3�t APPLICATION FOR SANITATION PERMIT Permit No. .-!._ �.1... 4Com lete in Duplicate)--.--------- -- -- ------- -- ----------------------- -- { i p P� ) Date Issued ------- ------ This Permit Expires ] Year From Date Issued Application is hereby made to the Sen Joaquin:Local Health District for a permit to construct and install the work herein described. This application is made in compliance with County Ordinan�5 , JOB ADDRESS AND OC ION / ---------- -- • •-----....----------------------------••---- •---- - AOddress.Name r.- = `=�4s Phone, i.... .. ... Contractor's Name........... ------------ j .......... Phon Installation will serve: Residence C5"'Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: ._. Number of bedrooms a___ Number of baths _/___ Lot size .---..�D ..... -Water Supply: Public system Community system ❑ Private ❑ Depth to Water Tabled_ ft. Character of soil to a depth of 3 feet: Sand P// Gffravel ❑ Sandy Loam E] Clay Loam ❑ Clay E] Adobe�ardpan ❑" Previous Application Made: {If yes,dater_�Q No E] Now Construction: Yes E] No �HA/VA: Yes [I No El TYPE OF INSTALLATION AND SPECIFICATIONS: *No septic tank or cesspool permitted if public sewer is available within 200 feet.) Distance from nearest well-----------------Distance from foundation_.....-____________-Material-------------.-----------_---- No. of compartments----- ------Size-------•------•----------------Liquid depth---------- --------------Capacity....................... Disposal Field: Distance from nearest wef .-_Distance from foundation__,-jO__`_.._Distance to nearest lot Gie__1 fine____ Number of lines_______. - Length of each 'Q______r/____-_.Width of trench.__ t Type of filter material-ti1_R-Pc!*_Depth of filter material---/9-----------Total length.................. .......... \ aes Pit: Distance to nearest well______________________Distance from foundation....................Distance to nearest lot line......... G, Number of pits--------_----------:Lining material----------.------------Size: Diameter------------------------Depth__-----•--------------- Cesspoo. Distance from nearest well_________________Distance from foundation------------'_-_Lining material...........__-________-_._---__...::. , ❑ Size: Diameter----€------+----------:----------- Depth----------------------------------------------------Li Liquid Capacity q -------------------•-.......gals, Privy: Distance from nearest re est well-________________________------------------------Distance from nearest building ❑ Distance to nearest lot line---------------------------------------------------------------------------------------------------------------------------------------------- f Remodeling and/or repairing (describe):--------------------------------------------------------------------------- - i •-•--------------------------------------------•----•-----•----•----------------•---------------•-•---•--------I'll-,----------- -•----------•----------------------------•---•----------------••-•-----------------•--•--•--- --•--------------------------•-------------•-- I hereby c i that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, St a aw�ules en iregulations of the San Joaquin Local Health District. (Signed)-------- • -- -------------- ` ______________ __ _�_ ner and/or Contractor) By:---------------_---•-••-------------------- •--•-•--• ------- -- -------•-----------•--•------------------------{Title)_....._ -, (Plot plan, showing site of lot, locati system in rel on to wells, buildings, etc., can be placed on reverse side). . FO EPA T� M�ENT~USE ONLY------------- DATE — -- APPLICATION ACCEPTED BY--- --- � -- � _ REVIEWEDBY--------------------------- -•-•--------- -------------------------•----------------------------------------••----•------- DATE— PERMITISSUED------------------------------------------------------------------------------------------------------ DATE J Alterations and/or recommend'ations:-------------------------------------------------------------------------------------------------------------•----.-- ••••---------------•---------------------•-----------------------------•-•-••------------------------------------••---•----•---------------------------------••-•-•---•-------------------•--••----------------•-•-•------ - � 3 _______________________________-----------------------------_------------------------------------------------------------------------------------- __________________________________ r ` �J � - - � 1 FINAL INSPECTION BY ._-- /- _ Date-------------- --- -�___-_L. ----- I SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak.Street 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,California Mantua,California Tracy,California E6 9 REVISED a-g9 RM 5-61 ATLAS l