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FOR OFFICE USE: ------ -------------------- -; ! 7 - ---- APPLICATION FOR SANITATION PERMIJ Permit No. ..............._....... ----------------- --------------------------------------- (Complete in Duplicate) _ 3 _________________________________________________________ This Permit Expires 1 Year From Date Issued Date Issued ___.....I.............. i Application is hereby made to the San Joaquin Local Health District for a permit to constru and Inst I1 the v pr �herein,d s had This application is made in compliance with County Ordinance No. 549. Gs.+ �i-w.t C i JOB ADDRESS AND L CATION....... ..-.l 'l = =, ... —.. -- - ,� Owner's Name-------__.... -- ____._----- ..--- Phone. Address------------------------ I Contractor's Name-----........----•-------------- ................. ----------------------- .--- Phone--••---••------•••- ------------------------------------------- -- . _ .....---------- Installation will serve: Residence ❑ Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other IN •e .-�,, Number of living units: Number of bedrooms .../... Number of baths ___,,t!.. Lot size -- -------2_ :__- - .__ ..... Water Supply: Public system ❑ Community system ❑ Private q Depth to Water Table _2,fft. 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: Yes ❑ No [0 FHA/VA: Yes ❑ No 2 TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Ta Distance from nearest well-..---..---------Distance from foundation____----------------Material-------------------------_._..................... /IYf . of compartments---------•-------••-------Size............................-•-Liquid depth----------------------_--Capacity.....•........•........ Disposal Field: J✓Distance from nearest well_________________Distance from foundation.•...._.............Distance to nearest lot line................. El 'i5bar of lines--------__-•-----------------------Length of each line------------------------------Width of french................................... rof filter material.........................Depth of filter material-------------_---------Total length-......................................... Seepag it: /,, istance to nearest well______________________Distance from foundation------------........Distance to nearest lot line................. El / dumber of pits-----------------=----Lining material....-------------------Size: Diameter---------------_-----Depth-----------------•---------•-•-•- Cesspool: Distance from nearest well----------------Distance'from foundation-------------------.Lining material..................................... ❑ Size: Diameter --------•----------------- jr -------- Capacity----------------------------gals, Privy: Distance from nearest well_________________________ ---------------.--.-Distance from nearest building------------------------------------------ I'li ❑ Distance to nearest lot line-------------•--------- ---•-------------------------•-•-----•-•-•-•--------•--•---•-------------••-------•---------------------------------- mod ling and/or repairing 'L--r-- __ ....._..'! - ...__ -------- -------------- w -------- ---.-------_-- �--------- ------..o!le,ree f` ..m� ......... /•r� y, Rt ae• •---••-. --------- 0,jo-•--- I hereby certify that I have preparedthis appli n and tha# #}le work will be done In accordance with San Joaquin County ordinances, St fe laws and rules and re ulations of the Sp Joaquin Local Health District. \ Si ( 9reed)---- ----- -- - ---------------------------------4 ----------------------------------------------------------------------.(Owner and/or Contractor) By: -•--•------------------•---------------•• ------ ---------------------------------------------------------------(Title)-------------------- ............ -- -------------- (Plot plan, showing size of lot, locafion,of system in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY J APPLICATION ACCEPTED BY-- - --------•- -�-- --------------------- DATE----� --••--._... REVIEWEDBY_-----_----------- ----- -------------- -----------------------------------------------------------------------... DATE----.......................... ....................... 1 BUILDING PERMIT ISSUED----------------------------•-------------.....---------------—...................................... DATE ! t DATE....-----•--- -------`---"-s--^---------------- ------------ Alterons a d/or recommendations:_-_______________________________________ ____- - - r r --... = ---------------------..-_-.-- =----- -----------------.-----------------------.-------------------------------- ------------- - 1>> FINAL INSPECTION �Y:.--=-::.- �-rte------:----- ' cr f_ Dafie----------------- --"- 3 -------------------------------------------- SAN�JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 Wert Oak Prow 124 Sycamore Street 205 Wert 9th Street Stockton,California Lodi,California Manteca,California Tracy,California ES 9 REVISED B-59 8M 5-61 ATLAS