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rvK vrrlC.t u6t: ---------------------------- -------------- ---------- f: ------------------------------------------------------- APPLICATION FOR SANITATION PERMIT Permit No. .. :�' ---------------------------------------•----- (Complete in Duplicate) '----------- This Permit Expires 1 Year From Date Issued Date Issued Application is hereby made to the San Joaquin Local Health District for a permit to con ruct and install the work herein described. -.a This application is made in compliance with County Ordinance No. 549. D5S —03p -jam' x JOB ADDRESS AN±D�� LO ATION explaa........................ I Owner's Name------- *� , •-•-- I Address............... / "' '-r-� �4_.... P�f6 Contractor's Name--- x,.Zr� 1+...- Installation will serve: Residence'❑ Apartment Hou e ❑ Commercial Trailer ourt Motel ❑ Other ❑ Number of living units: ........ Number of bedrooms -------- Number of bath�-_� Lot size --12k/V-Q.�..................................... (Water Supply: Public system ❑ Community system ❑ Private ❑ Depth to Water Table A__ ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe❑ n ❑ Previous Application Made: (If yes,date____________________) No New Construction: Yes No ❑ FHA/VA: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if pu lic se er is available ' hiri 200 feet.) _ . w _. -,: Y4 Sic Tank ' "'�Dis�ance from nearest wel Distagc� fm n___________________Maferial_ il __:- �' —,, ..:_,Liquid �. No, of compartments____- _________ ___Size ._ - _ . -de th_..______ ---------- Capacity../kW Disposal Field: Distance from nearest we ----Distance frown...— �.'wDistance to nearest lot Iir1e._.4�_-_f._... o 7678 � �.. e� �y Number of lines_____ ____________ .--___.- --'Leng+h of each line.....f_l�T1.-._.-_______-Width of trench.:...T__CF .�'._._________...__ Type of filter materia. Depth of filter material..___ E.''......Total length.....Z'4":..................... Seepage Pit: Distance to nearest we I----------------._Distance from foundation..::.-.._-___-..Distance to nearest lot line__-_•_---__--____ ❑ Number of pits----------------------Lining material_--------------..------Size: Diameter----....................Depth-----------_-.------------,------ 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----------------•--------------------------------------•--------------- � l Remodelingand/or repairing (describe):--------------------------------------------------.......-------•-••---------........................ ---------------------------------------- ---------------------------------------------------1----------------------------- ------•--------------•---------------•---------•----------•---•-•------------------•-•----------•------•---------------------------------------------------.-------------------•---• --------------------------------- I -•---------------•-••------- •---••----- ------•--•-----------------------------------•---•---------------------------------------••---•-.......................----------------------------------..----------- I hereby certify that I have prepay +his application and that the work will be done in accordance with San Joaquin County ordinances. State laws, and rules and 8 la ons of the San Joaquin Local Health District. (Signed) (Owner and/or Contractor) 9 )----•----------------------•---:.._.. By--------------------------------------- -•- ----- ------------ Title (Plot..plan, showing size of lot, location o system in r lation to wells, buildings, etc., can be placed on reverse side).._ - _ -_ -.ed a f e FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY- � , '-------------------------•----------------------------- DATE----- r-_.G-� REVIEWEDBY------------------•------------------------------------------------------------------------- •----------------------------.... DATE------------------- ` BUILDING PERMIT ISSUED-------------------------------------- --------------------------------......------------------------ DATE_._. Alterations and/or recommendations:-------------------------------------- -- -- -----•----------------•------------------I....... I ...................................--••---------•---------••----------------------• -------------------•--•----------------•----...--•---•--------_---..-----------------....-- -------------- t --------------------------------------------------------------------- ---•-------------------...._ •------------------------------------------------------------------------------------ ----------------------------- -----------------------------------•---...... --------------....-----------------------------••-----------------••--•-------•--------•--..-..__._._ i FINAL INSPECTION BY: Date- -_(2-... SAN JOAQUIN LOCAL 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 CS 9 REVISED 5-99 ZM 6-61 ATLAS