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rvKVrrll,t UJt: ------------------------------------------------------ ---- - --- .... .......... ...._.........--......-_---.--. 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. �/ s JOB ADDRESS ANPLOCATION___.----.�-.._•_----- ___f�.l-cls___ . �5x Owner's Name-- --•• ------•- -------- Phone-------------------•--••-. . •-- Address ------ o� �= ......... ------------•-- -----------------------------•---•--...---------------•--............................................---•---•----------------- Contractor's Name...--- • -------------------------------------------------------- --- -------•--------------- Phone................................... Installation will serve: Residence� Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: _.I.... Number of bedrooms .1----- Number of baths .I... Lot size -------��._.�'�''^��.,-----------_------ Water ____________ ______Water Supply: Public'system ❑ Community system ❑ Privateo Depth to Water Table ._ ft. Character of soil to a depth of 3 feet: Sand E] Gravel E] Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe Hardpan C]Previous Application Made: (If yes,date--------------------) No� New Construction: Yes No ❑ FHA/VA: Yes ❑ No � i TYPE OF INSTALLATION AND SPECIFICATIONS: ' (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic hk: Distance from nearest well-----------------Distance from foundation---------------------Material---------........................................ No. of compartments--------------------------Size--------------------------------Liquid depth---........---------•----Capacity....................... is yo(sal Fie Distance from neares well_.�b-----Distance from foundation_-__. -------Distance to nearest lot line-._�t� � Number of lines....... ...... ----Length Length of each line_._:__��C?... _�e f..Width of trench._._,��.-6..`��.........__...._ Type `_.Depth of filter material___.-. :.-....Total length-_•_-. BQ. T e of filter materials --.--- Seepage Pit: Distance to nearest well----------------------Distance from foundation-------------------.Distance to nearest lot line----------------- 11 Number of pits----------------------Lining material__,--------------------Size: Diameter------------------------Depth----------.-..------..__...••--•- Cesspool: Distance from nearest well.................Distance from foundation.-------------------Lining material_....-------....__..._----- .__..... ❑ Size: Dia ---: Depth - - -,...quid.Capa,city_ _-----------------•_:gals. Privy: Distance from nearest well ........................._------.._---.....Distance from nearest building--------------...-_..__._----------------- ❑ Distance to nearest lot line Remodeling and/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 Sta laws, a d rules and regulations of the,San Joaquin Local Health District. , Si` d ( 9ne ( -- - - .t ---------------------------------------------•-------- ------(Owner and/or Contractor) By............ ------------------------------------------------------------------------- ----------------------------------------(Title) (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY I r APPLICATION ACCEPTED BY---------------------------------------------------- -- -------------------------------•-------- DATE-------•---... REVIEWED BY - -- - - ------- DATE-------- y -_�f• BUILDING PERMIT ISSUED - -- ------ DATE_..---••---•-••--....................... > . Alterations and/or recommendations:.------------------------------------ --------------------------------------------------------- ---------------------------------- ---------•------.--•---------------------------------•----------------------------------- -•-------------------------- •---------------------------- -------------------------------------•---------------------------..---------------------------------------•--- -------------------------------- ------. ..------.... - -----------------•-------------------------------------- ---------•-----------------------------.--.--------------------------•--------------- f FINAL INSPECTION BY:. ---••---------- - -- .Date---------- ----------- --------- --.�'" � 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 ES 9 REVISED B-99 2M 6-61 ATLAS .a