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FOROFFICE USE: - ----------- --------------------------------- --------- ---------------------------------------- - ------------- APPLICATION FOR SANITATION PERMIT Permit No. _--•--- •----------... --------------------------------------------------------- (Complete in Duplicate) - -------------------------------------------------- This Permit Expires I Year From Date Issued Date Issued ......./..!1.. .._ 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 LOCATION_ Owner's Name---- __- -- - ------------ --- --------- ----------------------- -- Phone--------------- -------- --------- - - -------------------- Address- 1 �o -•--• ------------------- ----------1!•........... t...... ----- Contractor's Name ------_---•- ------------------------•-------...I-------------------------------------------- Phone...................-----------,- Installation will serve: Residence ® Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: ....___ Number of bedrooms ..- _ Number of baths 1__->r_ Lot size -------- _y_, __Aeg .......................... Water Supply: Public system ❑ Community system ❑ Private R Depth to Water-Table 7.Q.. ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam fJ `mak Adobe❑ Hardpan IM Previous Application Made: (if yes,date--------------------) No 0, New Construction: Yes ❑ No 10 FHA/VA: Yes ❑ No ❑ TYPE 01= 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_______......-.._-_.Material................................................. ❑ No. of compartments-------------- -----------Size------------------ ••._..:---Liquid depth--------------------------Capacity....................... 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 of filter material_________________________Depth of filter material----------------------- otal length........--------.___.________-_--_-_.-•_-_ Seepage Pit: Distance to nearest well--- ----------Distance fro foundation.... .a,4........Distance to nearest lot line__'+`_____._ 1E Number of pits------/---------------Lining material.-07 ---------.Size: Diameter---a .._......._...Depth---,_,....................... Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material.....__________________-----_------_- El ize: Diameter------------------------ ------Depth----------------------------------------------------Liquid Capacity----------------------------gals. Privy: Distance from nearest well______________ _______________________________Distance from nearest building------------------------------------------ El Distance to nearest lot line------------- �---------------------------------------•--------c--------------------••-------------------•------------.----------------------- Remodeling and/or repairing (describe):------ -----zt--�/_...... - ---------------------------------------------------- ------------------------------------------------------------------------------ ----------------------------------------•-•-------------------------------.----------.---------------------------•----------------------------------------------------------------------•A---------------.---------.------- hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinancesZSt a laws, and rules and regulations of the San Joaquin Local Health District. (Signed) -------- -------••---•• ---------------------------------------------------------------- _-----------------(Owner and/or Contractor) By:................------ ----------------_._ -- --------•------------------------------------- ---------------------(T'iifle)-----------_-------------------------- - --- ------ (Phot 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 -------------------------------------•-------------------- DATE - ` REVIEWEDBY------------------------------------------------------------------------------------------------------------------------------ DATE----------------------- BUILDING PERMIT ISSUED---------------------------- -----------------------------------------------------------_---------- DATE-------------------------- Alterations and/or recommend'ations---------------------------------------------------........---•--------------------------•------.------------•---------------•----------••-•---------------.. -------------------------------------------------- ----------------------------------------------•--------------••--•-----------------------------------------------•-------_...-...------------------------------------ ----------------------------------•-••-------•-----------------------------------•---•------------------------------------------------------------------------•----•--- ........-----------------------------•--------------- ----------- f FINAL INSPECTION BY:. ------------•---------------- Date.--fa--, '{4. ..----------------.-._-.__..------------ SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Strout 300 West Oak Srreet 124 Sycamore Strout 205 West 91h Street Stockton,California Lodi,California Manteca,California Tracy,California ES 9 REVISED 8.59 ZM 5.51 ATLAS