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FUKU✓-HU U5E: k I 7 't ------------------------;r •---- - --------------- --------------� _ ______________ APPLICATION FOR SANITATION PERMIT Permit No. ..... �.7.� --------------------------------------------------------- (Complete in Duplicate) ---- ------------ - --- This Permit Expires i Year From Date Issued Date issued .... Application is hereby made to the San Joaquin Local Healfh 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 LOCATION = k /------ -- ----------- ---- ..4.0 f -�r Owner's Name. --- - ---------- - --------------------------------------------- Phone �i ;, ' Address - ,C�!?. •- --. � 6 -----.•--•• --•--•--------•-•------------------•---- T i Contractor's Name..- � .. ...L1 ----__-----•------•-------- Phone................................... Installation will serve: Residence ❑ Apartment House ❑ Commercial W Trailer Court ❑ Motel ❑ Other ❑ Number of living units: _______ Number of bedrooms .------- Number of baths ..4.. Lot size ---.-----------............................................. Water Supply: Public system ❑ Community system R, Private ❑ Depth to Water Table ________ ft. Character of soil to a depth of 3 feet: Send ❑ Gravel ❑ Sandy Loam ❑ Clay Loam a Clay ❑ Adobe❑ Hardpan ❑ Previous Application Made: (If yes,date--------------------) No New Construction: Yes �q No ❑ FHA/VA-. Yes ❑ No�K TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tank: Distance from nearest well_.._._-__._-----Distance from foundation_____-e�o._...._.Material..._ �!...._. No. of compartments----• - -------------size----•..........------------- --Liquid depth__,' ---------Capacity-_,/ -C3 Disposal Field: Distance from nearest well_____—_-.._.Distance from foundation....../.C)-____._. (stance to nearest lot line--.J......... Number of lines--------------- g �� Width of french......�_____ ________ -Length of each line______ � � O Type of filter material.... -_ __. __ _Depth of filter material-------.le _.Total length_._.... :f�_.:C� r______..__-- A- S e'epage 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)---------I------------------------------------------- -----------•-----•----------------.---------.... -------------------------------- -------• --- ••-----------------------------•-•--------------•------------------------------------------------------------------------ -----------•--------------- hereby certify tha ave prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State laws, nd rules end regulaf ns of the San Joaquin Local Health District. ' n ^ P ' _.•______________(Owner and/or Contractor) (Signed)-------•---- gY: --••---------------------------------------•-•••-•----------------------------•------•-(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-------------------------------- - �`5. --------------------------------------- DATE-----------`) .` _ -- -- -•- ----------------- REVIEWEDBY ----------------------- ------------------------------------------------ .... DATE BUILDINGPERMIT ISSUED....--------------------------------------------------------•----------------------------------------- DATE----------------------------------------- Alterationsand/or'recommendations:------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------ .. ---------------------- -----------------....----•---------.....------•-•--------------------------------------------------------------• -------------------------------=-----------•--------------------------------•- •-----------------...- ----------------------------------•------------------------------:------------------------------------..._....------------------------------------ ------------------•--••-------- i FINAL INSPECTION BY:..... ......... - ------._ _ Date ----•---- G f - -- I }' SAN JOAQUIN LOCAL HEALTH DISTRICT 730 South American Street 300 West Oak Street 134 Sycamore Street 205 West 9th Street Stockton,California Lodi,California Manteca,California Tracy,California ES 9 REVISES 2-99 2M 5-61 ATLAS