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FOR OFFIC�YSE: APPLICATION FOR SANITATION PERMIT Permit No. .-......./...... -------------------------------------- ------------------ (Complete in Duplicate) Date Issued -------------------___.-.--------------------------------- This Permit Expires 1 Year From Date Issued Application is hereby made to the SanJoaquin 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. JOS ADDRESS AND LO/CATION_..-� -------- --- ---------------------------•--.........................---................................................. Owner's Name- )rl ----------•------- Phone------------------•----------------- -f-•------------•--------------------------- ---------------- Address-----•--- `�~° --------------------•-------•-------------•-•- ...................--------......................................•••......................... Contractor's Name----- .�7`=---------------------- - Phone.. Installation will serve: Residence [T--Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ f � r Number of living units: -L._--- Number of bedrooms ..Number of baths .1... Lot size _.. o-X_-L�-r ....... ...............•--•- Water-Supply: Public system [8Community system ❑ Private ❑ Depth to Water Table..: . rft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay❑ Adobe Hardpan ❑ 1 Previous Application Made: (If yes,date--------------------) No [?-_"New Construction: Yes E'No ❑ FHA/VA: Yes ❑ No g _- TYPE OF INSTALLATION AND SPECIFICATIONS: r (No septic tank or cesspool permitted if public sewer is available within 200 feet.) SP t' T nk: Distance from nearest well-_254 --Distance from foundation.......... - ........ . Material__ J��a�c�'t 'c No. of compartments------ ------------- Size-------�._.�5---__•-.,g:__.Liquid de th-_••--Y_.-:---- ------ � •- Disposal Field: Distance from nearest well_ --Distance from foundation..IQe--•_--.........Distance to nearest lot lin ,--........ Number of lines-------------- --------------------Length of each line---------�Q-----.....---•.Width of trench------ - Type of filter material._7R*ej�------_Depth of filter material - -----------Total length--------------- --_--_-------___- ' Seepag Pit: Distance to nearest well__e1%e+>Z.-._-.-_Distant m foundation___f._P�+!�ck.Distance to nearest lot line_-A.��------- \ Number of pits=-----=--- -----------Lining material_�Cf.----Size: Diameter---- 33.'`'_-__.Depth.......... a. s- 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-- ------------•-----------••-----------•-------•--------------------------------------------------------....----------••-------------------. Remodelingand/or repairing (describe);-------------------------------------------------------------------- - ....................-- ------------------------------------•---------------- ---------------- 1 ' •-----•-•-•-•-----------•----•-•---------•----•-------------•-••------------------------ ------- --------------------.-------------------------------------------------------------------------------- -----------------------------------------------------------------------------------•-------------..---------------•--.---------------------------.....-------..------------------------.--.-.....--------.-.-..-------------- I hereby certify that I have prepared this ppiic ion and that the work will be done in accordance with San Joaquin.County ordinances, State laws, and rules and regulat' sof he San Joaquin Local Health District. .(Signed)-------------------------------•----------- - - --------•---- ----- -- ----------- - --------------------------------•----------------------------------------(Owner and/or Contractor) By:.-----------------------------•----------- ----- --- - ---------------------------------------•---------(rtle)---------.-------------------------------------.. ------------ (Pliot plan, showing size of lot, location o stem in relati n to wells, buildings, etc., can be placed on reverse side). DEPART ENT USE ONLY APPLICATION ACCEPTED B ----- ---��O y'_'`' Y-----•-••-•------------------ DATE-------f,/- :7:-_1.J�` �---••------------- REVIEWEDBY--------_--------------- ----------------------- -------------- •-•------------------------ DATE--------------------------------------------------..-------- BUILDING PERMIT ISSUE Df4TE__-r--------__-- ,�+-- r' -• - -------..... ( and/or rec mmendations:---- 1 -'2 - �'� = - "`-------- Alterations, r r �/R�--fir • - - ----- ----.j�=�---- �-- - -------- •------------------------------ ----------------------------- ........................ FINAL INSPECTION BY:------ - - - �(,/4� --- Date---------�•�--.__:�'.��-. ' SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 Wost Oak Street 124 Sycamore Street 205 West 91h Street Stockton,California Lodi,California Manteca,California Tracy,California ES 9 REVISED 0•$9 YM 5-61 ATLAS