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t•UKUt-1-IfCEE USE: G�Z- ----- APPLICATION FOR .SANITATION PERMIT Permit No. .. ----- ---------- -------------------------------------- ! (Complete in Duplicate) / -------------------- ----- ------- Date Issued ----- ------------ - ---�--- This Permit Expires t Year From Date Issued Application is hereby made to the San Joaquin Local Health Distri.t for a permit to construct and install the work herein described. This application is made in compliance with County Ordinance V, 549. J08 ADDRESS ANDCATIONA� -�--• ------ Owner's Name ------ Phone------------•---_•--- - ----------------------------------------------------------------------- Address------- - - ------ ----- _ ..............---••---•-•--•------ Contractor's Name------------ --- -• :. _. . ----------------------- Phone......................... Installation will serve: Residence &'Apartment House ❑ Commercial Trailer Court ❑ ❑ Motel ❑ Other ❑ Number of living units: j___ Number of bedrooms J__ Number of baths _f___ Lot size Water Supply: Public system P.-tommunity system ❑ Private ❑ Depth ro Water Table A ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe(8/lqardpan ❑ Previous Application Made: (If yes,date____________________I No Z30' New Construction: Yes ❑ No [- FHA/VA, Yes ❑ Nom 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 _._________________._____..__..___...____._.... orgy?** No. of compartments--------------------------Size----•-------------------•-----Liquid depth--------------------------Capacity . Disposal F,il Idi Distance from nearest well________________Distance from foundation__________-___-____Distance to nearest lot line................. � ��s Number of lines-----•----------- ----------------•-Length of each line--------------------•---------Width of trench____••--------...-------• ``�� --------- t7c' Type of filter material-------------------------Depth of filter material----.------------------Total length_._____._.________...._ ----•-------------- Seepage Pit: Distance to nearest well----------------�____Distance from foundation___ _..- �. /�yyr� Distance to nearest lot line--i_____________ Lining material_/_�Q ----Size: Diameter--of pits----- ------- --- -- --------.Depth__, ---_.._------------ (� Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material.........--------------------- # l El Size: Diameter----}-------------------------------Depth--------------------•------------------------------Li Liquid Capacity q - ------------------• -••--gals. Privy: Distance from nearest well_______________________ _----:___,-----_Distance from nearest building -----------------_-•. i ❑ Distance to nearest lot linei A - -- -----------------------------••----------------•------------------•- Remodeling and/or repairing (describe):_________________ i ---- I---------------------------------- .......... --- ----•----•--•-------••------•---•------••------ 1 ---------------------•----•----•-• -------•----------•----------- --------- ------------------------------------------- ___1---------------------------------I------------------------------------------------------------ ---------------------11............... ----- - ----- -•--- -------- ------ -----• ----- ----- - ---- -- -- •--- -- --------------•- -•---- --- hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County I ordinances, State laws, anj rules and regulations of the,San Joaquin Local Health District. I (Signed)------- • .__ ------------------•--------•-•---------------- By:----------•• (rifle) r Contractor) -- ------- ---- - !l(�1i' {Plat plan, showing size of lot, location of cyst to relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY----J 1 �� r --- REVIEWEDBY---------------------------------------- - --------------------•----------------------------------------------------- DATE.--•-------------- SUILDlNG PERMIT ISSUED----------------------------�_ _ _ - -----------••--------;-------...------ ------ -------------.-•------ - ------------------- Alterations and/or recommendations:.______ �Q _ _ _ �'_�" /Gl ----------------------------------------------------------------------------------------------------------------------------- ------------------------------- -----------------------------------------------------------1 -------------------------------------------------------------- ---------------•---- I --•-•------ -----------•- •------------- ---------------------•-----------•----- -•:-------------------•---------- ------•-----------------------•- -------- ----- --- - FINAL INSPECTION BY:--- Date------.A--D77� J' r `- �� k SANS AQUIN LOCAL HEALTH DISTRICT r 130 South American Street 300 West Oak Street 124 Sycamore Street 305 West 9th Street Stockton,California Lodi,California Manteca,California Tracy,California E5 9 REVISED a-59 2M 5-6z ATLAS