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FOR OFFICE USE: j— ----------------- - -------------------------------. -- APPLICATION FOR SANITATION PERMIT Permit No. ..1 .. � -- ------- -------------------------------------------- (Complete in Duplicate) -------------------------------------------------- --- This Permit Ex ires 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 Co my Ordinance No. 549. /��'S JOB ADDRESS AN LOCATION �4_ ----Y -- �__._._l."... r Owner's Name- - ---- -------------- --- ------•------------- Phone--------••--------- --...-----••- Address_---------- .. -------------------- Phone Contractor's Name------------ 1.1 _.... Installation will serve: Residence [?"Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other Number of living units: .__f- Number of bedrooms -�__ Number of baths J. Lot size ---- -!�� ............... Water Supply: Publics stem ❑ Community system Private Depth To Water Table aft. Y Y Y ❑ X P Character of soil to a depth of 3 feet: Sand 9 Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe❑ Hardpan ❑ Previous Application Made: (If yes,date____________________) No ❑ New Construction: Yes ❑ NoR' FHA/VA: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) p' ank: Distance from nearest well-----------------Distance from foundation-------------------.Mater ial-----------------,...................._--------_. �/�` No. of compartments--------------------------Size--------------------------------Liquid depth--------------------------Capacity....................... L - r 7r- ! i Distance from nearest well '4----.-._Distance from foundation---✓_ -__--_-Distance to nearest lot line_- ....... Number of lines ,_-_ 6_ ` C LL--��-----_--_-_Length of each line -Q...............Width of french.-----s�-�-------------------- Type � -----------•--- Type of filter material.-5 __-Depth of filter material------,l.__3---------Total length......................... ...... Seepage Pit: Distance to nearest well----------------------Distance from foundation-------------------.Distance to nearest lot line----------------- El Number of pits----------------------Lining material-----------------------Size: Diameter.----------------------Depth--------------------------------- Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material----------.---------------........... ❑ Size: Diame+er._. ------Depth----------------------------------------------------Liquid Capacity----------------------------gals. ku Privy: Distance from nearest well------------------------------------------ -----Distance from nearest building______._______________-____-________._._. ❑ Distance to nearest lot line----------------••---------- ----------------------•-•---------•--..----.--..----...---••------------------------------•--------------------- Remodeiing 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 jjrdjan Joaquin Local alth Disfric . (Signed) ` i� caner and/or Contractor) Ry...----- - --- - �'-- (r+le) r-------------------------- - (Plot plain, showing size of lot, locatio of system in relation to wells, buildings, etc., can be placed on reverse side). I/ fZ ZR DEPARTMENT USE ONLY oe APPLICATION ACCEPTED BY-------- ------------- ----•-------------- DATE------- -------------------- REVIEWEDBY---------------------------------- - ---------------------------•-----•------- DATE-------------------------------------------- ------- BUILDINGPERMIT ISSUED__...... ----------------------------------•----------•------------------------------------------- DATE------------------------------------------------------------- Alterations and/or recommendations:------ -•-------------------------------------- ---------•-----•---•------••----•--_-.--------•--•--•-•-------------•---.-------•----------•----------•------- -------------------•---•------------------------•••------------•-------------------------------- -----------------------------------------•-----------•------------------------••--.--•---•------•------------- -•------•-----.•---•----------------------------- / •------•-------------------- FINAL INSPECTION BY:.--- � ------ Date-----------------•-- �� r��`� SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 124 Sycamore Street 205 West 4th Street Stockton,California Lodi,California Manteca,California Tracy,California E5 9 REVISED a-59 2M 5-62 ATLAS