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FOR OFFICE USE: ' APPLICATION FOR SANITATION PERMIT Permit No. _..1...��..�.......` ----- -- --- --- -------------------------------- --- (Complete in Duplicate) � Date Issued _..: _________________________________________________________ This Permit Expires i 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 Ordin ce N 549. t JOB ADDRESS AND OCATION._----/j0..-3- __---- -------------------------------- Owner's Name `-� ...r._ ---._. Phone....................--_-----_--- Address------------------------1117-------- ........_Address-------------------•----11-17---••--- --- 1--------•--•-•-•---••----- --•-----••-•--•--•-•......-----... Contractor's Name.. ...... ... ....•----- ... --•-••-•. ....... ............. Phone Installation will serve: Residence [Its Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: __ _ Number of bedrooms _&;2. Number of-baths _/-_l Lot size .... .'_________________ Water Supply: Public system +Community system ❑ Private ❑ Depth to Water Table 1/:: ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe 2-10ardpan ❑ Previous Application Made: (If yes,date--------------------) No [IB-' New Construction: Yes ❑ No g3--,�FHA/VA: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) is n := Distance from nearest well_________________Distance from foundation....................Material................................................. No. of compartments--------------------------Size---------------------------_.---Liquid depth-_. -_----.-------------Capacity....................... spDs- ig 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 Pit: Distance to nearest well-_)142'e'-_.Distance m f ndation....Zs�..-____-.Distance to nearest lot line................. Number of pits-------1...--..-----Lining material__-,..Size: Diameter.__......I------_-------Depth-------e?--S.............. ..• ` Cesspool: Distance from nearest well----------------- from foundation---._-_.....__.._-_.Lining material.._-._______._______.---------------- ❑ Size: Diameter--------------------------------------Depth----------••-------•--------------------------------Liquid Capacity............................ c Privy: Distance from nearest well------------------ _-._____---____. -------Distance from nearest building_________._-__-____--_-------_---_-___._. ❑ Distance to nearest lot line-------- ----------------.............................................---`•------- ...---------------------------------------------------- I Remodelingand/or repairing (describe)---------------------------------------------------------------------------------------------------------------------------------------------------------- ---------------------------------------------------------------------------------------- ------•----••----------------------------•----•----------•---------••--------------•-----•-----...._..._---------------------------------------------------------•---------•------•------••-------------------------------- I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, S laws, and rules and regulations of the San Joaquin Local Health District. E (Signed).. .. __ ...° .. ....... .................................................. wner and/or Contractor) By:.................................. - = ------------------------------------------- triifle)--- ---- (Plot plan, showing size of lot, loco+ion of system i lation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY---- ,Y�_ __ 16,-( DATE -`- .r � REVIEWEDBY--------------------------------------a ----------------------------------------------------------------------------------- DATE-_.----••--•-----------------------•-------••-------I...... BUILDING PERMIT ISSUED----------------------------------------------------------------------------------------------------- DATE-----------•------ Alterafions and/or recommen ations:-•----------------------- ............... --.-...................................................... ----- �,, - z t?: ------•----------------------•------------------------- --- ------------------------------------------------------- ----------•...................................................................... ---- .........----•----•----------.._......--------•----------•---- FINAL INSPECTION BY:--J ---- ------------------- Date--- �r--1---•`- </------------------------------------ SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 124 Sycamore Street 305 West 9th Street C % Stockton,California Lodi,California Manteca,California Tracy,California rh 1 ES 9 REV16E0 6.99 9M 8.011 ATLAS `