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FOR OFFICE USE: - -------------------------------------------------------- APPLICATION FOR SANITATION PERMIT Permit No. ..�..,�..�-.... --- ----------- ----------------------------------------- (Complete in Duplicate) Date Issued This Permit Expires I 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 L CATION...... ._ ._0_____C_.___ '_ r`............ . Owner's Name------..... � J •.-- •---- -= - -------- Phone 1.. d =--- ----- L Address..---------- --- ----------------------•--•----• ----------------•-•-•-•--------------------•----•--•------- Contractor's Name..... ---------------------••---------- •-----•-----------------------------------••-----••---------------------- Phone_--_-----------•-------•------- Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: _1_____ Number of bedrooms ..-, -. Number of baths . . Lot size ------9P_.17..a�..^__So........................ Water Supply: Public'system Community system ❑ Private Depth to Water Table S ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam Pa Clay Loam ❑ Clay ❑ Adobe❑ Hardpan ❑ Previous Application Made: (If yes,date____________________) Nom New Construction: Yes No ❑ FHA/VA: Yes ❑ No ❑ t TYPE OF INSTALLATION AND SPECIFICATIONS: ib" (No septic tank or cesspool permitted if public sewer is available within 200 feet.)% i 1 �. Septic Tank: Distance from nearest well_________________Distance from found ____ ation_ ,__-----__-__.Material....-....-----.---------........................ ❑ No. of compartments--------------------------Size------•--------•-------------'_Liquid depth--------- --=-------------Capacity....................... Disposal Field: Distance from nearest we€l._.•r___1_------Distance from foundation__#10____-___.Distance#to nearest lot line...j6r_-___--.- 1B Number of lines__________________ ___ Length of each line___?-0j--!_._______._.Width of trench_____;�.-_Y....................... Type of filter material...�___ ____� Depth of filter material...... . 9_______Total length-----FOP------------------------------ Seepage •_..-. .__•______________Seepage Pit: Distance to nearest well------V_v--------Distance irom,foundation-VI&'.........Distance to nearest lot lin-_-- Number of pits------j--------------Lining material_.A_I�d---------Size:.DDiameter...3.3 S _--_____.____.Depth.-.2 _____.__....______.__ Cesspool: Distance from nearest well-----------------Distance from-foundafion--------------------Lining material..__.___....____________________--•_- Q ❑ 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):--l�C�f�i _ �s't'1IL .figs'+�i ••------•-------•-----••----------•---••------------- 1 - 1 I I- I hereby certify that I have prepared this application and'that the work will be done in accordance with San Joaquin County ordinances, State laws, and rules and regulations of the San Joaquin Local Health District. r* (Signe : .. f =------------- ----------------------------------,-.-.------------------.-----------------.(Owner and/or Contractor) ' --= ----------- rifle)------------------------------- (Plot plan, showing size of l;ot, locat in of system in'relation to wells, buildings, 'e+c., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY ---- - ...'-------------------------- DATE------ -r•---------`--------------------- REVIEWED BY -------------------------------------------- -- DATE---------------------------- BUILDINGPERMIT ISSUED---------------------------------------------- -------------------------------------•----------------------------------- DATE------------------------------------------------------------- Alteratipons and/or recommendations:----•- --------------------------------------_----------•-----•-••--- ' -----•---•-----------------------------.................. -------- ---------•----•------- -----------------------------•-•- ._........._--------------- •. -- ._: - •••-- ..-------------------------•--•-•------ ---•-••---•--•--------•--------------•-- --------------------------- f. `{ ? •--------------------•-----•--••-•----•-----------......_-------------------------••-•-----••-•-----------•---------------- 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 i EE 9 REVISED 8.69 9M 5-61 ATLAS