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FOR OFFICE USE: ---------------- ---- - ------ / -- -------------------_-..__.___.__--._..___-______ APPLICATION FOR SANITATION PERMIT Permit No. .•._,� �/ j ------i z� This----------- (Complete in Duplicate) /D ' - i ----------- -- ,� Permit Expires 1 Year From Date Issued Date Issued Application. is hereby made to the San Joaquin Local Health District for a permit to constrct and install the work herein described. This application is made in compliance with County Ordinance No. 549. JOB ADDRESS AND'LOCATION. - •- --l ---_--- 'k Owner's Name__..__: w ------------_-- -------------------------------- Phone----------------------------------- Address_ '.'_ ---- _ '----------------------------- ......................•.------•-•-•.......---.--•-•---.--... Contractor's Name .........'------------------------------------------------------------------........-------------_-----__ Phone......................------------ Installation will serve: Residence ] Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: -_-- Number of bedrooms �.... Number of baths a-..-_ Lot size J _�?_ _ 6 4.................•..-.•....___ Water Supply: Public system ❑ Community system ❑ Private 11 Depth to Water Table k ft. Character of soil to a de th of 3 feet: Sand Gravel s f p ❑ ❑ Sandy Loam Clay Loam ❑ Clay ❑ Adobe❑ Hardpan ❑ Previous Appiication'Made: (If yes,dote__.___._-_.;___.-_.) No � New Co struction.- Yeses No ❑ FMA/VA: Yes ❑ No❑ TYPE OF INSTALLATION AND SPECIFICATIONS: I "j (No septic tank or cesspool permitted if public sewer is a`vailable`within 200 feet.) - Septic Tank: Distance from nearest well *......_..Dista a fr m foundation._/�_-----------Material-___s' 10--'�-"_. ............•_-. 1 " No:.of,com artments- ?'_ 1- P r --- Size ' f-------- ---- -Liquid de th---.-Y--------- Ca aci /2f!P1t Disposal Field: Distance from nearest well_ ✓ ____..._.Distance from foundation__-4�___---.----Distance to nearest to line---:�......... Number of lines......_----_ ,�r ___Length of a F dine_..�lo____________________Width of trench--2-1. -___________...___---_ Type of filter materiaY E _-Depth of filter material_`.,E��-------------Total length___ -i .._..______._...___._.____ i 'Seepage:Pit: Distance to nearest well______________ Distance from foundation___•_-_-__-.•.___.Distance to nearest lot line________.__...... ❑ Number of pits........ Lining material..........-------------Size: Diameter------_----_----------Depth-----------------............... r Cesspool: P Distance from nearest well------------ _Distance from foundation--------------------Lining material------------------------------------- ❑.. f Size: Diameter--------------------------------------Dept h-----------------------------------------------------Liquid Capacity............................gals. Privy: Distance from nearest well_______________ ---------I.-Distance from nearest building------------------------------------------ ❑ Distance to nearest lot line --- ---••------------------•-•-----• ...-...-------------- i Remodelingand/or repairing (describe)----------------------------------------------------------------------------------------------••----•--------•--•----•--•-•------•------•------•---..---- -•----•----------- ----------------•------------- --------•-•-----••---------------------------------------------------------•--- ----- •--------•-----•---------•----••--•-----------•------------------- --...--•-------------------------------..............•------.---------------------------------- --------------•-•-----------------------•--------------------------•----••------------------------•-------------•-•------• i I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, S e laws, and rules a I re ations of the San Joaquin Local Health District. (Signed)___ __ R ; _____________________(Owner and/or Contractor) sy----- ------------------ ----------- ---- - - --------------------------------------------------------------------- (Title) ------ ------------- —Plot"lan sh win size o lot"locafion of s stem in gelation"to we11s;litiildin'-s, etc can be' laced ori reverse-sid"e). ( P� 9 y g� P - 1, FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY. � -----------------------------•----------•-----•--•� DATE `' � •- REVIEWEDBY---------------------------------------------- --------------------••--------------------------. --------------------------- DATE........................... BUILDING PERMITISSUED..................... T-----=-------------•-------------------------••----------------•----------------. DATE------------------------- Alterations and/or recommendations:--------------------- •------------------------------------------------------------------------------------------------- e �..o �� FINAL INSPECTION BY: .c Date SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 124 Sycamore Street 205 West 9Th Street Stockton,California f Lodi,California Manteca,California Tracy,California tt 9 REVISED 8-99 2M 6-61 ATLAS Y -