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FOR OFFICE USE: 1 b _________________________________________________________ APPLICATION FOR SANITATION PERMIT Permit No. .......... ........... --------------------------------- ------------------- (Complete in Duplicate) 2_-. ----------------------------------------------------- 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. C" ,e ,'j JOB ADDRESS AND CATION.1 - 1l -� * ��/ d"_..__.._ _ ...... Owner's Name........ ....... amu_._ j .....-- • -• . f c C` ---------------------------------- ---------------------------•-----. Phone... •--•- -----•-- Address......................./L� __ r, Contractor's Name.= ----------------•--••------•-••-•----•--•-•-•--_... Phone................................... Installation will serve: Residence, partment House ❑ Commercial ❑ Trailer Court ❑ ,,ttMotel ❑ Other ❑ Number of living units: ... Number of bedrooms ----l_ Number of baths .../-- Lot size .__....(V_�.- x...G_. ?__- ................... Water Supply: Public system ❑ Community system K Private ❑ Depth To Water Table .. ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam JV Clay Loam ❑ Clay ❑ Adobe❑ Hardpan ❑ Previous Application Made: (If yes,date--------_____-------) No D�' New Construction: Yes No ❑ FHA/VA: Yes ❑ No TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tank:' ance from nearest well--------•------.-Distance from foundation....................Material-------------•------•---------....._.._....---•. i ;- of compartments Size Liquid depth Capacity AJ Disposal Field: Distance from nearest well/6-0-0_._Distance from foundation..__./-'5.........Distance to nearest lot line—.5-- r, ine—.5--..... �7 [ Number of lines_____ ___________ _r Length of each line....... 7 -__ _:_ n.Width of trench.... ��.__�_..._._..__._._ /� r Vii` '"� Type of filter material...1 .1- depth of filter material.....___ .....Total length----.r�.{..Q........................... d Seepage Pit: Distance to nearest well----------------------Distance from foundation....................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---------------------------------------------- -------•-•---•----------------....-•----------•---•--------•--•- •---------------------- Remodeling and/or repairing (describe) ---------•---------•----•--------•--------------•---••-------•--•--•-•---•-----•-----•-••------•---•---••--•----•---• 16 --•------•----••-•-----------••----- --•-----------•--------•-------------------------------------•-----------------------•---------------•---------------------------------------------•--•------•-------••----- •------ - 1 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin Coun ordinances, State , a ules regulatio a San aquin Local Health District. Si ned. Z__..�.! s_____ ___.______Owner and/or Contractor By:--------------------------------------------------------- -•--•----• - ----------------------------------------------------------(Title)-------------------------------------------- -- ------------- (Plot plan, showing size of lot, location of system relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY------------------------------- DATE �.. fd REVIEWED BY-------------------------------------------------- DATE ---------------- BUILDINGPERMIT ISSUED.......................=�-'`--= -J------------------------------------------------------- DATE......................................................... Alterationsand/or recommendations:............................................................................................................................................................... ---------------------------------------------- --------- ------- --- ----------..------------------------------------------------------------------•------------............................... FINALINSPECTION 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 8.59 2M 5-62 ATLAS