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FO OFFICE ------------ ------------------ ii:�� -____�� 3LV APPLICATION FOR SANITATION PERMIT Permit No. . ..... .. ---------- `= "---------------------------------- (Complete in Duplicate} Date Issued .... ----- This Permit Expires 1 Year From Date Issued �..7....�� 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 LOCATION.... .. ---- ' arta Owner's Name------------ - -_ ,� - •-_-_-- --------- - ----------------------------------------------------------------------------- Phone.............._.-................... Address-------!�' ---------------tf �?fir... ------ ------------------------------- Phone.---------.....---•-......-------• Contractor's Name.........�------ -- ----------•-----•--•---- -------------------------- - Installation will serve: Residence ❑ Apartment House commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: .ct�.-__ Number of bedrooms -------- Number of baths , ..- Lot size .41� -.-'X---- ......................... Water Supply: Publics stem f y Community system ❑ Private ❑ Depth ro Water Table _�ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe Er-Tlardpan Cl Previous Application Made: (If yes,date-------------_..-__) No JR`* Construction: Yes ❑ No g4--FHA/VA: Yes ❑ No g— 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---------------.----..............----_----.--.-. jenS ITy No. of compartments--------------------------Size---•----------------------------Liquid depth--------------------------Capacity-----------------_---- Dis�osal Fiekd- Distance from nearest well-----------------Distance from foundation--------------------Distance to nearest lot line__............ Number of lines---------------------•------------,Length of each line-----------------------.--....Width of trench----------------------------------- Type of filter material-------------------------Depth of filter material-----------------------Total length_----------_-_-.-_-_.................... Seepage Pit: Distance to nearest well---!- -------Distance fromf undation______PflZDistance to nearest lot line�;10,_..-_. Number of pits---- --------------Lining material-t .Size: Diameter-_- __.--------Depth---rZt '----._----_-----. 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-------------- ----- ' --------------------------------------- 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, State laws, and rules and regulations of the San Joaquin Local Health District. (Signed) ` � '' / ------------------{ Lor Contractor) J --- •--.---------- -----By: - -- ----• Title ----------------- ---------------- { ) 'J (Plot plan, showing size of lot, location of system in tion to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY_____d__ •-----------------------------•--------- DATE--• ^_S-=-6Q-- -------------- REVIEWEDBY----------------------------------------- ----------------------------------------------------------------------------•- DATE---------•-•------... BUILDINGPERMIT ISSUED--------------------------------------------------- -----------------------------------------•------- DATE.-_--------------------------------------------------•----- Aiterations and/oec mmend'ations:-�j--------- --- lz----------------------------------- -------------- ------ -------------------------------------• - --._ i 1 --lc ..--..�- i J . ------- -------------------..... ------------------------• ------ FINAL INSPECTION BY:... ------------ Date----- ---------- ---•--••------• --- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 124 Sycamore Street 205 Wert 9th Street Stockton,California Lodi,California Manteca,California Tracy,California ES 9 REVISED S-59 21A 5.62 ATLAS