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FOR OFFICE U,5E: '- Permit No. ._.,�s �....... APPLICATION FOR SANITATION PERMIT ------- -.--------------------------------------- (Complete in Duplicate) Date Issued ... �` K ------------------------------------------------------------------ This Permit Expires 1 Year From Date Issued _" Application is hereby made to the San Joaquin Local Heal+h 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 PLATIO ��/ i � � ---------------------•--....----•• --•-•---- - Owner's Name---------- ........ ------------------------------------••----- -------- Phone Address----------------------------------- Contractor's Name.----•-___ ----------•--------•--- --------------••----------.....---- Phone--./...fl.-...`�..`.'_7.�� Installation will serve: Residence Apartment House ❑ Commercial E3-,Trailer Court ❑ Motel ❑ Other ❑ ` Number of living units: _J.___ Number of bedrooms -Z—Number of baths ---Z- Lot size .kit- Clay - -- - -••---• Wates Supply: Public system ❑�ommuriity system ❑ Private ❑ Depth to Water Table Character of soil to a depth of..3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ ❑ Adobe Hardpan ❑ Previous Application Made: (If yes,date______________:__--) No New Construction: Yes [D No HA/VA: Yes ❑ No TYPE'OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) S Tank r Distance from nearest well_________________Distance from foundation--------------------Material_____..._____.-____-----........................ tic No. of compartments--------------------------Size----- •-•------------- ---------Liquid depth--------------------------Capacity---•---•----•--• J Dis osal.R d:r -W Distance from--nearest well_-.____"'_____-.Distance from-foundation... _-�-� Distance to nearest lot line-'.°�".......... Number of lines------------ J-----------------Length of each line------ � --- -Width of trench---- ----------- Type of filter material/1 ___t:OC---Depth of filter material_._ _" -. -"Total length...... _....-------------- ..."-_-- Seepage Pit Distance to nearest well----------- from-f u `da tion__1�__..._....Distance to nearest lot line_.�.�__... Number of pits______ _________ Q� T__ Siiei'Diamefi�r...=� ^^ .. / Lining mater!al. L ----•---.Depth----�-�----------------- r Cesspool: Distance from nearest well______----___..._Distance from foundation--------------------Lining material.___._--...___-.-.____••-___.__. `JV Size: Diameter--------------------------------------Depth---------------------------- Liquid Capacity gals. l Priv Distance from nearest well_,.-----------------------------------------------Distance from nearest building___-•________________"-------------_-----. Y ------------ Distance to nearest lot line---- -----••------• --•-- - ---------- ------•------ ////.JJJJ..------ --•• ---•------------••-•------------- I .................................. Remodeling and/or repairing {describe)----------------- -----•-------------i----••-------•----,-------------- -----------,..._� +` I = -------•---- I ••---------•----------------- f k __________________________________________________________________________________________________ - I ' --------- •-•-------"• - ----- ------------- ---- - 4 I hereby certify that I have prepared this application and,that-the work will be done in accordance with San Joaquin County ordinances, State laws, and ruf s"and "�alf the SJoaquin Local Health District. {Owner and/or Contractor) $i ned ----------�(iv.1-t..� i- -•-- --- ' I - .- - {Titla� By=---------- -------- •• - ( (Plot plan, showin st of lot, ocatian of system in relation to we s, uildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY L y I APPLICATION ACCEPTED BY `-1------------- ------------------------------- DATE.. -------•------------------ ! REVIEWED BY DATE ----------- -------------------------------------- BUILDINGPERMIT ISSUED------------------------------------------- ----------------- DATE-------------••---------------------------------------•----- AFteratio and/ recommenda ons------------------------------- --------- L�yv�-... -� --_ .�- - ----•-----�- lelr----------•----------------•-•----------------••---•----••----•-----...__.. -•-------------------•-•----•"--------•------••----•------ - I --I----------"------------- F ______________"__..__--______.__._.-______._____..._.__ .___ FINAL INSPECTION BY:.. ---"-_-- - ------ Date.-- --J---6-6-0Z— SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 124 Sycamore Street 205 West 91h Street Stockton,California Lodi,Califomia Manteca,California 7raey,California ES 9 REVISfO B-89 YM 0-61 ATLAS I