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FOR OFFICE USE: _________________________________________________________ APPLICATION FOR SANITATION PERMIT Permit No. -------•-------•---------•---------------------•- (Complete in Duplicate) / Date Issued .._ --------------------------------------------------------- This Permit Expires 1 Year. From Date Issued ..__..�.f.�?..�- 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 ION. . . o� '�-�� Owner's Name......... •-------•-•-...�.......... ----------••---•---••-------• Phone.................................... Address........ .--- ---� ------- --------�-....... . 0............. -------............ Contractor's Name............. ..... .... �___..__ Phone.._ Installation will serve: Residence Apartment House ❑. Commercial E] Trailer Court C] Motel ❑ Other Number of living units: ....1_.. Number of bedrooms _Iy,-- Number of baths .../.. Lot size ..... ................................. Water Supply: Public system ❑ Community system 10 Private ❑ De to Water Table ........ ft. th ❑ Character of soil to a depth of 3 feet: Send ❑ Gravel Sandy Loam Clay Loam ❑ Clay [3Adobe❑ Hardpan ❑ Previous Application Made: (If yes,date--------------------) No New Construction: Yes V No ❑ FHA/VA: Yes ❑ No)] TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Sep Tenk: Distance from nearest well/li!. .f"_Distance from four�dation----J�.•.._..___.MgtefieL.......................................:....... iIx No. of compartments.._-�----------------Size.,K}C_/,0.x__,----------Liquid depth_•..�--___ ....Capacity... Dis o I Field: Distance from nearest well_�e"_Distance from foundation....:1.0.........Distance to nearest lot line._ ......... Number of lines....._1__________ __________ ____Length of each line-----1R..V..__.___.._ -Width of trench.,P-4`0 . ....... A� ------- Type of filter material. Tji__0 �____De Depth of filter material...,/$. .Total length _SI:Q......................... YP P 9 � •- 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---------------------------------------------------------------------------------------•----•--••----•-------•---------•-••••......-•-•_.._.. Remo"sling and/or reps'ring (d scribe):_____ ....... '= ----- . y4 _� ...........................•........-------------- ----•••--- ------ ------•---------------------------------•------------------------•------. q1 ff I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State and rules and regulations of the San Joaquin Local Health District. Si ned u 0— -------•-------•---------------------------------------••-.---- Owner and/or Contractor By:....................................................................................................................................(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 APPLICATION ACCEPTED BY------------------------------------ ---------- ----------------•---•------------ DATE....................................................-•••-•- REVIEWEDBY................................................................. ................................. DATE----- }..........0......0...... BUILDINGPERMIT ISSUED....................................... ---------- •---------------------------------------- DATE----- �-......... -.....-- Alterationsand/or recommendations:............................................................................................................................................................... ..................••--------•------------------.._......-----•---•--------------------------------------- .................................--•-..................................................................I......I..... •-.......................................••----•-.....•-•-•......-••----------------------•------•-•••-•-------------•--•----•--•-•-------••---•----•---•------------------••----•---••-----•-••--•------••--••--••-•-•--••-- ....................................................••-•••-••-'..................................... ------.................................................................................................................. ............................................................ FINAL INSPECTION 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 E6 9 REVISED 8-89 RM 8-61 ATLAS