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FOR OFFICE USE: �—• APPLICATION FOR SANITATION PERMIT Permit No. .j.. _._ '----------f----------.-_ ---____--_--_________._------ (Complete in Duplicate) Date Issued -„-------- Expires -_- ;/1- ---E -------" This Permit Ex fires 1 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 O finance No. 549. .. . ,.-Y - ° t p JOB ADDRESS AN OCATION------ 5.--- -- - '- -- -• . --- -- ...... f -- ---------••-- -- •--- ..�� ✓/ Y:'_�.h------ Phone Owner's Name------- _ .-" _.•____-- - Address.-- * -- •------ '. --- Contractor's Name__--__ ,---._.... Phone__-_---._-."_ ..._......_ lnstallation will serve: Residence Apartment ouse ❑ Commercial ❑ Trailer Court [jMotel ❑ Other ❑ Number of living units: T_- Number of bedrooms Z.. Number of baths/ Lot size ............................................................ � Water Supply: Public system El system ❑ Private Depth to Water Table -------- ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel F1Sandy LoamX Clay Loam Clay F1Adobe[3Hardpan ❑ Previous Application Made: (If yes,dote--------------------) No [INew Construction: Yes E] No [IFHA/VA: Yes E] No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: , } (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tank: Distance from nearest well_________________Distance from foundation----.---------------Material................................................. ❑ No. of compartments-------------------- Size-.------------------------------Liquid depth--------------------------Capacity---------_--__ .,.. Disposal ield:' Distance from nearest well�Fe_._._.Distance from foundation-_..�.©..6___.Distance to nearest lot ne._F�. .._._..__ p Number of lines--------_-_-�------------ -- Length of each line--------(2-t�."-.- �__._..Width of trench-----�•----T.__--""""-- Total length-------_- � -----------•-----••-- I .� Type of filter material._._. ---Depth of filter mate _-Tota t Seepage Pit: Distance to nearest well----------------------Distance from foundation.._f_.......-__-"_.Distance to nearest lot line .. ❑ Number of pits---I-----------------Lining material---------------•-------Size:: Diameter------------------------Depth------.---------.-.---_"_-.-_---_ Cesspool i- Distance from nearest well-----------------Distance from foundation--_._---_.:___-._.-.Lining mater iel.__________..______.....________----. ❑ Size:-Diarrieterti_i.---•--------------- ------Depth-------------------------------------------------"'Liquid Capacity_ gals. Privy: Distance from nearest well--.--------------------`-----------------'---Distance from nearest building---------------------------------......... Distance to`nearest lot line-----------"-------•------------------------------------------------•-------- /. e, Remodeling and/or repairing (describe}:-------- t ------- t1i----------------------------------- -...! -------------------•-------- ---------- 1 e 1 F i' ► t fit ----- •---------------•------ --------------- ---------------• --------------------------------------------< S -ui 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 and;pegulations of the San Joaquin Local Health District. ` = " (Owner and/or Contractor) .. - -------------'---------'- --------- (Signed) r cy B . -------- ------- --- - ------- ----------------(rtlel.................-•----'•--- --------------- --------------- (Plot plan, showing-size of lot, loc on of system in relation to wells, buildings, etc., can be placed on reverse side). 1 FOR DEPARTMENT USE ONLY APPLICATION'ACCEPTEDBY--------- ---- - ------------ ----------------- ---------------------------------------- REVIEWED ----------------------------- -REVIEWED BY------------ = ":...' .-------------------=------------'"-------------------------_------------• - DATE-------- •-•----------------------------•----•---•-•------._ . :J% • �= '% ',DATE---------------------------------------------------------- -1------------ BUILDING PERMIT'ISSUED--------------------------------------------------- -------- ._----•---------------- Alterations and/or recommendations --'-- ------------••---------•----- ..:... - 1 ti -------------------------- ' FINAL INSPECTION BY: Date ' g SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street ' 300 West Oak Street 124 Sycamore Street 285 West 91h Street Stockton,California 1 Lodi,California Manteca,California Tracy,California EES 9 AMSEO 5-59 pM 6'61 ATLAS -