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FOR OFFICE USE: r' Q� � O�IS ----------------------------------- --------------------- N .. _________________________________________________________ APPLICATION FOR SANITATION PERMIT Permit o. YX ------------------------------ -------------------------- (Complete in Duplicate) ------------------------------------------ -------------- This Permit Expires 1 Year From Date Issued Date Issued Application is hereby made to the San Joaquin Local HealthDistrict 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 {O TION �� l� t .. Owner's Name.. t--------------- ,�s1....�. Ph ne._:........._.....:...... Address......../_S l- f-7 Contractor's Name............. ...........................--•••---....................................................................... Phone................................... Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other Number of living units: J..... Number of bedrooms ---1---- Number of baths ....�. Lot size ... 3...X./A.-O......................... Water Supply: Public system ❑ Community system I Private ❑ Depth to Water Table ........ ft. Character of soil to a depth of 3 feet: Sand Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe❑ Hardpan ❑ Previous Application Made: (If yes,date------_-------------) No New Construction: 4b No ❑ FHA/VA: Yes ❑ No, TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septi Tank: Distance from nearest well.-©0--Distan from foundatt- �:_.�0__...._...Materi I. ..( -:3AC, :c '/. �. No. of compartments____--0- --______---Size.6�/Q._,I('..?.Liquid depth........... __Capacity..l'T...... .... Disposal Field: Distance from nearest well.-_/O-.?Distance from found ion....L6........Distance to nearest lot 1.''n� rp......... Number of lines................... ........... Length of each line:.-.. .._.. �d� of trench./....;.L• ....... ......... Type of filter material. pth of filter material.�$�' _____________ olral length......46,0---��t-t?)........ "® Seepage Pit: Distance to nearest well----------------------Distance from foundation....................Distance to nearest lot line----------------- 11 Number of pits----------------------Lining material------------------- Diameter........................Depth................................. Cesspool: Distance from nearest well.................Distance from foundation....................Lining material..................................... Q5 ❑ Size: Diameter......................................Depth----•-------------........_....--�--------------Liquid Capacity............................gals. Privy: Distance from nearest well------------------------------------------------Distance from nearest&ilding.......................................... ❑ Distance to nearest lot line--------------------------------------------- --•-------------- ---- --------•--•---•----•---•---------------•-------•- -•-------------- r Remodeling and/or repairing (describe):-------------------------------------------------------------------------- P02 0.................................. ..... ---•-•-- ......-_.. •------•--•-----------------------------••---------•-------••--•-•-------------------•--------------------•--------------------------------•----------•-------...------------------•--------•--•-----...--•-----._....._..._.. I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, a laws, an rule pand re ations of the San Joaquin Local Health District. (Signed)...a . . • --• •----•. ... . �.�+ --------------------------------------------------------------(Owner and/or Contractor) By:--•-----•.............•-----•-•-------••---•.....-••----------------------------------..._.---------------•----•--------------------(T'iifle)--------------------------------------•-- (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 R APPLICATIONACCEPTED BY-------------------------------------------------------------------------------------------------- DATE............................................................ BY DATE BUILDING PERMIT ISSUED....................................... DATE..----- �•---•••.•-----•---•---•-.y - f 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 Wast 9th Street Stockton,California Lodi,California Manteca,California Tracy,California ES 9 REVISED 8-89 RM 5-61 ATLAS