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FOROFFICE/USE: 2- ------ -- ________--------------------------- APPLICATION FOR SANITATION PERMIT Permit No. -------------------=----------------------------------•--- (Complete in Duplicate) /?� G 7� ------------------- This Permit Expires I Year From Dale 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. JOB ADDRESS AND LOCATI N_ Owner's Name__ __ v ------- Phone------------------- Address-- Contractor's Name----- - -- --------- ----s S- -----------•-------•------------------------------------------------------•---------•----•..- Phone.................................. Installation will serve: Residence eApartment House ❑ Commercial ❑ Trailer Court ❑ Motel. �]� Other ❑ Number of living units: _I_____ Number of bedrooms_-_ Number of baths j-___ Lot size -___-. ........__ Water Supply: Public system ®'Community system ❑ Private ❑ Depth to Water Table�_l__ ft. 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 99-"-New Construction: Yes Ra 1Vo ❑ FHANA: Yes ❑ No [ � TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) S.-p ' Tank;._ Distance from nearest well-----------------Distance from foundation....................Material-------------------------------------- .......... A/,Vk-7 No. of compartments-------------------------Size.....----------------------------Liquid depth--------------------------Capacity.........._.._....... D�i os i Distance from nearest weli!>` _____Distance from faundationl�_f________.Distance to nearest lot line..3 .........�r� Number of lines-------------;- Length of each - Number of trench.....°Z.- _*------_ .-------.. Or Type of filter material 4`. ---Depth of filter material-41_____________Total length_____-..-----_-_-•--_--__-_-__--•__ r -- Seep Pit: Distance to nearest wells --------------Distance fry foundations-__.........Distance to nearest lot line•.•._..._._ Number of pits--------i............Lining materia l-----_-_ 2 _Size: Diameter__-.3.3.?`-._...._.Depth______________ rJC"'_...... 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 --- •---------------------------- Remodelingand/or repairing (describe)------------------------------•-•---------_---- ------------------------------------•--------•------•----------------------------------------------- •-----------------•----- ----•-•-----------• ---------------•------------------------•---•---•--••----- --------------------------------------------- -----•--------------•-------••.....------- --------------------- I hereby certify that I have pre ed th's application and that the work will be done in accordance with San Joaquin County ordinances, State laws, and rules a egul ions of the San Joaquin Local Health District. (Signed)------------------------------------------- ------ --------------- ---------------------------------------------------------------•- ------(Owner and/or Contractor) By ............................ _. _.... .•----.---- --- - ---------•--------------------------------------------------(Title)---------- • ---•--------------------- -- -------- (Plot plan. showing size o lot, loc ion of system i relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY --- --------------------•-1•-------------------- DATE------i!�• Q _.. REVIEWED BY------------------------------------------------ -- ------------------•-----------------------------------•-----------------• DATE---------•--•---------------------- BUILDINGPERMIT ISSUED--------------------------------------------------•------------------------------------------------- DATE--------•-------------------------- ..... Alterations and/or recommendations:--------------- _---------------------------- ---------------------------------.....------...---•-----•-----•----.....------•-----------.-..--••------ --------- • = ------------------------ ------------------------------------------------- , 5 't . - r ...A4r;/ .. _-------- FINAL INSPECTION BY:,--- ------------•----------------- Date---------Olcc)ll� �.... SAN JOAQUIN LO AL 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 B-59 Zhr 0-61 ATLAS A