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FOR OFFICE USE: --------------------------------------------------------- PLICATION FOR SANITATION PERMIT Permit No. .....--,-:--...-_--. AP --------------------------------------- - --------------- (Complete in Duplicate) Date Issued ---------------------------------- --------------- This Permit Expires 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 Ordinance No. 549. JOB ADDRESS AND OC TION- Owner's Name----- ------------ Phone................ ---------- ------------ ------ ------ ----------- Address.----- -�-----)5-�---A.Al + Contractor's Name ---------------------------•-------------••------------------------------------------------------------------ Phone-- -------- Installation will serve: Residence ❑ Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ OtheZc Number of living units: -------- Number of bedrooms -------- Number of baths -------- Lot size ----� -�...--�-c- ....-_-- Water Supply: Public system ❑ Community system ❑ Private V Depth To Water Table I_ ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam K Clay Loam ❑ Clay ❑ Adobe ❑ Hardpan ❑ Previous Application Made: (if yes,date--------------------) No-le New Construction: Yes No [-I FHA/VA: Yes E] No4K TYPE OF INSTALLATION AND SPECIFICATIONS: {No septic tank or cesspool permitted if public sewer is available within 200 feet.} „ / i Septic Tank: Distance from nearest well----�� Des#ante from foundation....f-.........._.Material- ---- -- ------ --- ------------ a No. of compartments-..-_--1--7 -�-.--Size-_��?( X--��..L.iquid depth--------------------------capacity---a�A.A_ Disposal Field: Distance from nearest well.4, 10--_----Distance from foundation..- .7.......Distance to nearest lot line._-------- Number of lines------d3....--- -- Length of each line--------1- �Cpa - Width of french----- ..�! �� Type of filter material$-- Depth of filter material---1_�-- -----.Total length__-...34;�--- _.------ ,/%Seepage Pit: Distance to nearest well----_.--_---.--------Distance from foundafiio� ._. .......Distance to nearest lot line----------------- ❑ Number of pits----------------------Lining material-.---------------------Size: Diameter----------_---__-----Depth--------------------------------- 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-------------------------------------------------------------------------------------------------------------- Remodelingand/or repairing (describe):-----------------------------------------------------------------------..._..--------------•--------••----------------------•------..-------...._.------ ------------------••---.....---•---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------•-_-----------------------•-----------------------..-..------------------------------.....----------•------------....----•----------•-----•---------------------- I hereby certify that 1 have prepared this application and that the work will be done in accordance-with San Joaquin County ordinances, State laws, and rules and egulations of the San Joaquin Local Health District. d r; �� {Si gne }-------- - --- -- -- •----------._-'�. --=�°_-- - --- -- -• -{Owner and/or Contractor) B • (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 APPLICATIONACCEPTED BY------------------------------------------------------------------ - ----------------.. - DATE-------------------------------------------- REVIEWED BY------------------------- ----------------------------------- DATE-----f' BUILDING PERMIT ISSUED------------------------------------------------------------ ... . ----- ------------ DATE------------------------------------------------------------- Alterations and/or recommendations------------------- ------------------------------------------------•---.....-------•-•------••--------•-•-------------•---••------------•-••-----•------------- --------------------------•--•--------.....---------•----...------------------------------------------------------ .......................•.............................................................-------------- FINAL INSPECTION BY----- ---------- Date--- -- ---- ----�-�------------------------------------ SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 124 Sycamore Street 205 West 91h Street Stockton,California Locil,California Manteca,California Tracy,California ES 9 REvlsEp 5-59 2M 5-62 ATLAS r