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--------- ---- . 7 ' t --------------------- 1Ia - -'-------- --------------------- ------- ----------- APPLICATION FOR SANITATION PERMIT Permit No. ------------------- (Complete in Duplicate) Application is hereby This Permit Ex fres f Year From Date Issued Date Issued ._....... ... ��-•� made to the San Joaquin Local Healfh District for a ermit too construct and install the work herein described. This application is made in compliance with County Ordinance No. 549. y}�,,� W �] ,1; 2 7 VVV `v (.c.►t.� JOB DDRESS AND LOCAT N Owner's Name_. - ' --------- Phone �.Address.- Contractor's Name------------ .� ........................I....................................... -•----•..--••-- -•- -_------ Phone................ ................. Installation will serve: Residence Apartment' House Commercial ❑ Trailer Court ❑ Motel I—] Other ❑ '� Number of living units: ..:.__- Number of bedrooms ._ Number f baths __ . Lot size __.... _ ___ ___ Water Supply: Public system ❑ Communitysystem } Y ❑ Private Depth to Water Table _!-fft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam W100colay Loam ❑ Clay ❑ Adobe❑ Hardpan ❑ Previous Application Made: (If yes,date--------------------) No ❑ New Construction: Yes ❑ No ❑ FHA/VA: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: g (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tank: Distance from nearest well_________________Distance from foundation-------------------MaterialEl No. of compartments------------- Size-------------------------------Liquid depth--•--- -•----Capacity Dispa t`Field: Distance from nearest well-----S o_ 'Distance from foundatio _...._. � p � � ff�� _ .._...Distance to nearest lot fine._.. Number of lines--------- �_____________ _ Length of each fine (._IQ. Width of trench.__.--,.. Type of filter material._._ _ Depth of filter material____ IT - ---------Total length------.�Q- .._...--- -- Seepage Pif: Distance to nearest well_________---------___Distance from four'dation____•--__....-_ ._._.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-_-________..__________-_- d/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, State laws, and rules 4andegulationsT of the San Joaquin Local Health District, (Signed)__._.__..-- ---------- - ---------- ------(Owner and/or Contractor) BY:- ---- le)-------------•------•--------------------- (Pic+ plan, showing size of lot, locystem in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY DATE-----�-'/2 --�---- - ----------------- REVIEWED BY ---- ------ ---------- DATE------------------------ -- BUILDING PERMIT ISSUED----------•---------- ------------------------------•--------------------•---- ----------------------------------• ---------------------- DATE--------•----------------- erations and/or recommenddations:-_____-___.-.-.___._ ----------------------------------- ------------- FINAL INSPECTION BY:. - - r _--- Date__..4_-/,r6�/ 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 EB 9 REV15 Eo 8-99 2M 5-67 ATLAS