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ruKurrii,,C uot: --------------- ------ ----------------------------- ------------- ----------------------- ------------------- ----------------------------______________________________________-_..___._____._-- APPLICATION FOR SANITATION PERMIT Permit No. ---------------------------- -- ------------------------- (Complete in Duplicate) 9//D� y -------------- -- -- This Permit Expires f 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 A County rdinance No. 549. I -- /� 0 7 JOB ADDRESS D LOCATION ---------- ------ "= ._... Owner's�Nam ". ..---•• .. one- �p --•--------------- ---------------------•---------------------- Ph --••----•---•---- •--•---•--•-••-- Address ---1 •-- . ----•- -•--• -• . --- ----...•---- ----------------------•--•----------.................................. Contractor's Name ---..------ Phone................................... Installation will serve: Residence ❑ Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: __I__-:Number of bedrooms -------- Number of baths ........ Lot size ..�.l *- .__ !___.:. Water Supply: Public system E] Community system E] Private Depth to Water Tabl ... __ ft. `� Character of soil to a depthof 3 feet: Sand E] Gravel E] Sandy Loam E❑ Clay Loam ❑ Clay E] Adobe Hardpan ❑ Previous Application Made: +{If yes,date-----------------------) No R1 New Construction: Yes Rr No ❑ FHA/VA: Yes ❑ N401._„ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tank: Distance from nearesf;well_________________Distance from foundation....................Material------------------------ ......... -------- ❑ No. of compartments.___---••----------------Size----------------------•- •-----Liquid depth--------- -------------Ca aci Disposal Field: Distance from nearest well_________________Distance from foundation--------............Distance to nearest lot line............ ❑ Number of lines-----------------------------------Length of each line------------------------------Width of trench----------------------------------- Type Pit: Distance to nearest well _ Distant from found tion___- �.Distalength...............................•___. ype of filter material________________ Depth of filter material_______---_______ Total nce to nearest lot line_ ........ ' Number of its__._ <<� p Lining maters : Diameter.-- ---------._.Depth__ it,F--••--------•- Cesspool: Distance from nearest well_________________Distance from ou ation_---_-.-___________-Lining material.............__.________------__.__._ ❑ ize' rnl�ter, . th -•--------- r --.-Liquid►Capacity------------------------....gals. iJ �-� - Privy is ance` o nea�es e ' ; g �. -------------------------- L �� ci' i e""ro°�fFirarest buildm ❑ Distance to nearest lot line---------------- Rom --------- - f Rem sling and/or repairing (describe :_ 1'___ - Aot-Vr.�C ----• - -•-r------- �t �, � � --Tp- ••------------- ------ --------- -- ------- .... ---- ----•--...------••----------•-----•--------- ------------•--------------------------- I hereby certify that I have.prepared this pplication and that the wor will be done in accordance with San Joaquin County ordinances State laws, and rules and regulations of the San Joaquin Local Health District. (Signed)-- I , ------------------------------------- ---------------------(Owner and/or Contractor7 ) By:... :_.... ----•-• -------------------- ....----------------------------------------------------(Title)-------------------------------------.-------------------------- (Plot plan, showing size of lot,location of system in relation to wells, buildings, etc., can be placed on reverse side). F FOR DEPARTMENT USE ONLY ,I APPLICATIONACCEPTED BY------------------------------------------------------ -------------------------•----------------- DATE----------------••------ --------- REVIEWEDBY --------------------------------------------- --------- ------ DATE.--. � - ---------- BUILDING PERMIT ISSUED--------------------------------------- - DA•TE. Alterations and/or recommendations ----- -•-•------•-------------—--------------------------- •---•-----•--••----------•-•--...------------------------.-..----------- i, ............. ---------------------•-----------•----------•---•-•-----------•--------------------------•- - .: r I' FINAL INSPECTION BY:-- ------•----- 1 Date----------------------- - ----------- SAN JOAQUIN LOCAL HEALTH DISTRICT f 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 8-89 pM 5-6[ ATLAS