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FOR OFFICE USE: ___________ ------------------------------------------------------=-- 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 construct and install the work herein described. This application is made in compliance with County Ordinance No. 549. JOB ADDRESS AND OCATIC)N__ _ __. __ . Owner's Name------ ..� ......... Phone: - Address . .. ----------------------- Contractor's Name.. ------------------------------•------------------- ------------ --- ---••---- Phone--------•--•... --•-------••-•--- Il, Installation will serve: Residence [D Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other C] Number of living units.-' J_-_- Number of bedrooms .3.:,. Number of bathss�..-. Lot size __ -_. *^�--.•----------------••••••••- Water Supply; Publics sterni Community system Privatt L9 ''D--MONO th to Water Table ��- ft. y i ❑ fY Y ❑ , �,� p � Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam Clay Loam ❑ Clay ❑ Adobe❑ Hardpan ❑ I Previous Application Made: (If yes,date____ _____________lLNo New Construction: Yes Da No ❑ FHA/VA: Yes ❑ No El i TYPE OF INSTALLATION AND SPECIFICATIONS- [No�septic,tank_or cesspool permitted,if.public sewn -available within..200Tfeet.], d� r r Septic Tank: `-=,�. A0istance ,from nearest well__�__Q.._____..Dista cs from foundation----/.0---__-.__Material _-�/_. _-- '✓ ..�-..................... . ' ` -..------Sikg ,• __Li uid de th___' /� Ca aci No. of compartments -- q p. P ty�Ata-V-_.._.. Disposal'.Field: .::,Distance'Jrom nearest well.,;_____--------Distance from foun a ion___C0______----.Distance to nearest lot line..t71........ - Number of lines...... -------------- ��---//--Length of each line_/ -------------------Width of french----A.Y.-9--......j�•.-3b i Type of filter materi�6t'D_ 0 4F___Depth of filter material----1-_,P_.._'_......Total length.__. _�a-------------------------•- Seepage Pit:' . Distance`fo nearest well______________________Distance from foundation_.............__._..Distance to nearest lot line----------------- r ❑ ; 1, 'Number of pits----------------------Lining material-----------------------Size: Diameter.........................Depth--------------------------------- iCesspool: Distancelfrom nearest well_________________Distance from foundation--------------------Lining material.------------------------------------ ❑ Size: Dielmeter----------------------- ------Depth_-..-------------------- ---------------------------Liquid Capacity--------------- gal Privy: Distance`from nearest well------------------------- ---------------------Distance from nearest building----------------------------.............. ❑ 'Distance to nearest lot line-------------- ----------------------------------------------•----- -•-•---- -------------- --------.--. ---------••----- - Remodeling.and/or repairing (describe):-------------------------------------------- ---------------------------------•-•--.....-------------------------...------------------------------------ -------------------- I herebcertify that l Have prepared this application and that the work will be done in accordance with San Joaquin Counfy ordinances.late laws, and rules dreguI�ari )of the San Joaquin Local Health District. By --- _______________________(Owner and/or Contractor](Signed)... ----- = •---- ---------------- -_ (rtl } Y ;(Plot plea s6awing size-•of loft, location iystemle relation to wells; buildings, etc., can be placed on reverse side]. FOR DEPARTMENT USE ONLY APPLICATION ACCEPTEDBY •rr C' -Q'- •--• •------------------ DATE-- r.. REVIEWEDBY---------------------- ----------------- ------------------------------ DATE BUILDINGPERMIT ISSUED!--•--•---------------------------- ------------------------------------------------------------.- DATE-------- ---------------------- •------------- Alterations and/or recommend'ations--------------------- ---------------- - -----••-------------------•--•----------------••----•-----__------•---•------------ ... ------------------------- ..............•---....----.._..._._ .-------- - •----------------------•---------.__- -•---------••------------- 'I' ............................ _.._..__. ----__.___-_------------------------------------------------- N ----- FINAL INSPECTION BY----- - ----- ---- -- .-- Date.-. SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 124 Sycamore Street 20S West 91h Street 1 - Stockton,California ! Lodi,California '`�, Manteca,California Tracy,California ES 9 REVISEO a-59 8M 5-61 ATLAS t t